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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID#I; SERVICE REQUEST# <br /> OWNER OPERATOR BILLING PARTI,i <br /> FACILITY NAMEAo�elAj� <br /> SITE ADDRESS r <br /> / 535-7 Street Number Direction Type Suite# <br /> Mailing Address (If Different from Site Address) <br /> CITY &0� Al STATE NT zip Q <br /> PHONE#1T• APN# LAND USE APPLICATION# ` <br /> ( <br /> PHONE#2T• BOS DISTRICT LOCATION CODE <br /> II - <br /> CONTRACTOR l SERVICE REQUESTOR <br /> REOUE5TOR BILLING PARTY Q <br /> BUSINESS NAME PHONE# r <br /> MAILING D ES �� <br /> CITY $TATE Z]P <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 ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this projector activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared licatfon a to be orm I e 0 accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FcOERAL laws. <br /> APPLICANT SIGNATURE: DATE: Xfly <br /> PROPERTYIBUSINESSOWNER ❑ OPERATOR/MANAGER ❑ OTHERAtiTHORIZEDAGENT <br /> YAPPLCANT is riot ft BiwmG PewrY,proof of aufhadzation 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 environmentallsite 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: I. <br /> COMMENTS: n <br /> I' <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: E"wPLOYtE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): I SERVICE CODE: P I E: <br /> F ! Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> I' <br />