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SERVICE REQUEST <br /> Tyke offBBus�ines o Pr pert FACILITY ID SERVICE REQUEST # <br /> d n� Q C g <br /> OWN R/ OPERATOR CHECK If BILLING ADDRESS <br /> FACIL NAME LG <br /> SITE ADDRESS I � J <br /> Strget Number 'Avi I DireCtlo� I NpTI12 Type Suite p <br /> HOME or MAILING ADDRESS (If Different from Site Address) �TT N u hyo <br /> b i �2o Z i t <br /> CITY STAT ZIP <br /> PHONE 1 <br /> EXT. APN # LAND USE APPLICATION# <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> R UESTOR CHECK If BILLING ADDRESS <br /> lyi tnSol� <br /> PHONE a Ext. <br /> Bu?N�/-"�AQE S� <br /> HOME or M✓��IL/ING ADDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKINOWLEDGEti(ENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific PUBLIC 11EAIA-11 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 the work to be performed will be done in accordance with all SAN JOAQUIN <br /> Cot INTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> .APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/ BUSINESS OWNER OPERATOR/MANAGER OTIIER AUTIIORIZED AGEN � <br /> If APPLICINT is not the BILLINGARTY,Pproof of authorization to sign is require) Tr'r!e <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 environmentaUsite 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 Al1''sl <br /> COMMENTS: RIF(.,. ". EDI <br /> AUG 311 <br /> ."i Al-.Jwt�"ullq U'. 'ViVTY <br /> PUBLIC HEALTH SERVICES <br /> ^JVIRONMENTAI_HEALTH MASIU <br /> INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVE Y: EMPLOYEE#: GATE: �( <br /> ASSIGNED O: EMPLOYEE#: ✓✓✓ DATE: GI <br /> SERVICE CODE: <br /> Date S,rvice ompleted (if already completed): (/� l <br /> Fee Amount: 3(. Amount Paid Payment Date 3I i <br /> Payment Type ✓ Receipt# Check # Received By: <br /> 7/l/1999 <br /> SRRIiOrev doc <br />