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Ah SERVICE REQUEST a <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />el <br />PCCGu s (r S r)pv av\) <br />PHONEq# ExT' <br />® 1 a 3 ;-)— <br />OWNER/ <br />OWNER/ OPERATOR <br />FAX # <br />( 2) 52Y-USv 3 <br />CHECK if BILLING ADDRESS <br />STATE C-41- ZIP �S <br />i/ <br />FACILITY NAME <br />ENVIRONMENTAL HEALTH DIVISION <br />INSPECTOR'S SIGNATURE: <br />SITE ADDRESS /_`(/ <br />APPROVED BY: <br />Street Number Oir i n <br />S r t Name <br />Type Suite <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />CITY -n <br />` <br />i7 <br />•/ <br />S_ TATE ZIP <br />`LAN�NDD <br />PHONE #t EXT. <br />APN # <br />SERVICE CODE: <br />USE APPLICATION # <br />PHONE #2 ExT• <br />( ) <br />Amount Paid 2 <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUEST t — <br />r 1fy--� t U t r <br />`J <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME �pe ,^t <br />PAYMENT <br />PHONEq# ExT' <br />HOME or MAILING ADDRESS <br />RECEIVED <br />FAX # <br />( 2) 52Y-USv 3 <br />CITY <br />STATE C-41- ZIP �S <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges <br />associated with this project or activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this application and that th ork to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standardss TE and FE I s. <br />APPLICANT'S SIGNATURE: I V DATE: 1-S�_ <br />PROPERTY/ BUSINESS OWNER OPERATOR/ <br />If APPLICANT is not the BILLING PARTY <br />1UTHORIZED AGE?tT �G"Uj�r� 1A Ht._ <br />to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and <br />at the same time it is provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />PAYMENT <br />COMMENTS: <br />RECEIVED <br />JUL 131W9 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY: <br />EMPLOYEE #:`U LI. DATE: <br />ASSIGNED TO: <br />2� <br />EMPLOYEE #: 1 1 J DATE: <br />i7 <br />•/ <br />Date Service Completed <br />(if already com ted): <br />SERVICE CODE: <br />P I E: <br />Fee Amount: �%' <br />Amount Paid 2 <br />Payment Date <br />Payment Type <br />Receipt # <br />Check # <br />Received By: <br />SRREQrev.doc <br />7/1/1999 <br />