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• SERVICE REQUEST . <br /> Type of Business or Property FACILITY ID# <br /> SERVICE REQUEST# <br /> E <br /> OPERATOR �C � BILLING PARTY <br /> Mfl,v��;�� -AME <br /> SITEADDRESS <br /> 131q Street Numbv 15-r/<A)r 01. VJZ- <br /> 0 T e <br /> P Su ep <br /> Mailing Address (If Different from Site Address) <br /> CITY <br /> STATE ZIP <br /> PHONE#1 Exr. qpN# LAND USE APPLICATION# <br /> ( j <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR(SERVICE REQUESTOR <br /> ;REQ,UESTOR � BILLING PARTY❑ <br /> NAME L � PHONE# EXT. <br /> I (DORE <br /> Sod FAz# by-83 <br /> , y� <br /> c <br /> BILLING ACKNOWLEDGEMENT: I,the unders' red property or business owner, operator or allthoriZed agent of same, acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALT (VISION hourly charges associated with this project or activity will be billed tome or my business as identified on this form. <br /> I also cemly that I have prepaar3tFi appll on and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. n - - <br /> APPLICANT SIGNATURE: <br /> DATE: L. <br /> PROPERNIBUSINESS OWNER ❑ OPERATOR/MANAGER C OTHER AUTHORIZED AGENT ❑ <br /> IIAPPUaAaTisnotfhe PaRry proof ofauthwization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmental/site assessment infomlatiOn to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the Same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: I ' n C 7 �/,�A RIF <br /> L <br /> E(,`f <br /> COMMENTS: l� (� J <br /> PAYMENT <br /> RFI EWD <br /> MAR 111999 <br /> SAN JOAOWN COUNTY <br /> PUBLIC HEALTH SPRVICES <br /> ENVfI?ON7v1ENTA1,HEAL7H OIVISIOA, <br /> INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY: EMPLOYEE#: 0 7 cl 3 - <br /> ASSIGNED <br /> - <br /> DATE: <br /> ASSIGNED TO: M rpt Z EMPLOYEE f: Q /, ( t DATE: 3 - d - 7q <br /> Date Service Completed (if already completedj: _7 SERwcE CODE: Z ?v P f E;a3 <br /> Fee Amount: ri 3 Amount Paid 42311 Payment Date 3 <br /> Payment Type Invoice# Check# Received By: <br />