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SERVTCE REQUEST EH006ISR revised 07/10/98 r <br /> Type of Business or Property FACILITY 10 SERVICE QE{�UEST M <br /> i <br />` OWNER I OPERATOR BILLING PARTY L <br /> I <br /> FACILITY NAME <br /> i k <br /> SITE ADDRESS <br /> Sheet Nvmbrr Oirecuan ShM Norte iype 5,titai <br /> Mailing Address (If Different from Site Address) <br /> CsTr STATE ZIP I <br /> PHONE#1 APN# LAND USE APPLICATION <br /> PHONE#Z M BOS DIS[RiGi LOCATION-CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> i <br /> REQUESTOR SILLING PARTY❑ <br /> BUSINESS NAMME PHONIi r' <br /> FAX# <br /> MAILING ADDRESS <br /> CITY STATE ZW <br /> BILLING ACKNOWLEDGEM>=N1: 1. the undersigned property or business owner, operator or authorized agent of Same, acknowledge that ail site <br /> and/or project specific PUBLIC HEALTH SawcES EtY1rIRo MENTAL HEALTH OMSION hourty charges associated with this project or activity will be billed to <br /> me or my business as identified on this forst. <br /> I also certify that I have prepared this application and that the work to be performed YAK be done in accordance with all SAN JOA4UIN COUNTY <br /> Ordinance Codes, Standards.STATE and FERAL laws_ <br /> APPUCAAT SIGNATURE. DA-M <br /> PROPERTY/SUSWESSOWNER I] OPERATORIMANAGER © OTHER AUTI40R®AG@rT Q <br /> IfAPFtr,WTis not the at U16 proof of avtlro&jtlon to s4o is required Vile <br /> AUTHORIZATION TO RELEASE INFORMATION:when applicable, 1, the owner or operator of the property located at the above site address,. <br /> hereby authorize the release of arty and all results, geatechnicai data and/or etvironrnental/site assessment information to the SAN JOAQUIN COUNTY <br /> PLIL3uc HEALTH SER%gi ES EwRaNmENTAL.HEALTH OMSION as soon as it is available and at the same time it is provided to me or rriy representative. <br /> ffoF SERVICE IZEGUESTED: <br /> Gjmmem Q SPECIALCONDIMN(S)OFAPPROVAL❑ OTHER Q <br /> ;NSPSCTOR'S SIGNATURE: CONTRACTMWS SIGNATURE: DATA <br /> 1 <br /> APPRavw Sy' :31PLUtEEr: DATE <br /> ASSIGNED 7-0: =4PLAYE~ DATE <br /> Date Service Comeieted (if already comnieted): E SEMACE r__-DE: <br /> =-e Amount amount Paid E Payment Oahe <br /> Payment Type Invoice;* I C.'Iedt# Received$y: <br />