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SERVICE REQUEST <br /> Ty f Business or Pr p 7fty <br /> FACILITY ID# SERVICE REQUEST# <br /> �x — A—- Flo `0 <br /> OWNER 1 0 F�1T� _ �\ � � BILLING PARTY El <br /> � G J <br /> FACILITY NAME <br /> [Y L' <br /> SITE ADDRESS �y) , <br /> Street Number Di ren 1/ / / SVeet Name Type Suite# <br /> Mailing Address (If Differe�tomSitedr s) <br /> CITY .,jATE <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# V <br /> aOfl 333(o,83 d <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUEST R BILLING PARTY i.- <br /> GF)c.P <br /> BUSINESS NAME / PHON # EXT. <br /> a e, Ci2 Z <br /> MAILING ADDRESSFAX# <br /> CITY t TATE zip G� <br /> `J <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMEUTqA HEALTH DIVISION hourly charges 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 prepare is a plication and that the work to beorned will be done in accordance with all SAN JonoulN COUNTY Ordnance Codes,Standards,STATE and <br /> FEDERAL laws. ` <br /> XA <br /> APPLICANT SIGNATURE: 6(XJ ) DATE: 41qAl <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ✓ r <br /> If APPucmr is not the BIwNG PaNrv,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,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 andlor envimnmentaVsfte 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 /> PAYMENT <br /> RECEIVED <br /> MAR 13 2001 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC ENVIRONMENTgtffH <br /> EAL �DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> n�Pnv'r'ED o Y: y W EMPLOYEE#: DATE: <br /> ASSIGNED TO: MSL EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: (� PIE: 2,�O e <br /> Fee Amount: 1 — Amount Paid Z��i Payment Date -3/ 1-3 /01 <br /> Payment Type ZO l Invoice# Check# 5 Received By: �. <br />