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• SERVICE REQUEST <br /> Typ Business or Pr erty FACILITY In g SERVICE REQUEST# <br /> Oo��%�2- S2C�b�-Somal <br /> OWN /OPERATOR ^� D J BILLING PARTY <br /> FACILITY NAME <br /> SITDDRESS ,(® A �, <br /> Street Number Directlon / a Type auiteC <br /> Mailing Address (If Different from Site Address) v, (&1V <br /> (�n/ 50 <br /> CITY h � STATE IP 'a^5-6;j� <br /> PHONE#t EXT, APN# LAND USE APPLICATION# <br /> — <br /> PNDISTRICT LOCATION CODE <br /> CONTRACTOR SERVICE REQUESTOR <br /> REO STO BILLING PARTY <br /> BUSINESS NAME Pill# <br /> MAILI D E�4S/� co1AX /—& <br /> lJll I W <br /> CITY ATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/oar project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEA rStON howdy charges associated with this project or activity will be billed to me or my business as identified on this form. <br /> 1 also certify that I have prepared this appli Nona that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERALIaWS. <br /> ^ n <br /> APPLICANT SIGNATURE: DATE: fJ / <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT '( <br /> lfAPPLIDANTiSnetfhe BrwNGPAR proof of authorization fa sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property located at the above she address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentaVsAe assessment information 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: <br /> COMMENTS: <br /> REC IVSD <br /> JAN 1 0 2001 <br /> POBL10 RpA THE ITR D V SIGN <br /> ENVIRDNMEN <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED oi: EMPLOYEE#: � DATE: <br /> AssIGNEDTO: 5 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICECGDE: P I E:23 g <br /> Fee Amount: (� d� 4mount Paid o2(0�, �� Payment Date D D 1 <br /> Payment Type Invoice# Check# L�y Received By: <br /> 10 or <br />