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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR BILLING PARTY 1 <br /> FACIE N <br /> SITE ADDRESS <br /> Street Numoar birectlon 1 �p �t Name I TYo� SmUf <br /> Mailing Address (If Different from Site Address) <br /> CITY G , STAT . ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> f ) <br /> PHONE#2 EXT. BO DISTRICT LOCATION CODE <br /> 7 <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY <br /> BUSINESS NAME PHONE# EST. <br /> 37 <br /> MAWNG ADDRESS <br /> Ax# <br /> qt' &36 -aG:.C41 <br /> CrTY �nC�W r \ 1 `", STATE CA ZIP (�5 <br /> BILLING ACKNOWLEDGEMENT: I, the unaersioned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project soeclfc <br /> PUBLIC HEALTH SERVICES EWRQMVENTAL HEALTH DMSIQN hourly charges assodated 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 prepay is nand that the work to be performed will be done in a=rdance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPUCANT SIGNATURE: DATE: <br /> PROPERTY 1 BUSINESS OWNER ❑ OPERATOR/MANAGER Cl OTHER AUTHORIZED AGENT <br /> !f AcPtr..wr is nor rhe 84Lr,c PAR proof of wthorizadon to sign is requir 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,geotechnicaf data and/or envlronmentaUSite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OrviSION as soon <br /> as it is available and at the same time it is orovided to me or my represen <br /> TYPE F SERVICE REQUESTED: <br /> COMME <br /> PAY e,,N'T <br /> FEB 2 5 1999 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISIONINSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: �rn r EMPLOYE`r#: (� C f DATE: ct e <br /> ' •\ �`� 0 <br /> ASSIGNED TO: D �t �-y� EMPLOYEE#: 3 DATE: ;L_ ';i-S <br /> Date Service Completed (if already completed): SERVICE CODE: D 34 1 P!E: Q <br /> =ee Amount: 7J C I Amount Paid 3 Payment Date I �� <br /> Payment Type Invoice# I Check# f a a y I Received By: <br /> J <br />