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e • SERVICE REQUEST EH0061 SR revised 07/10/98 <br /> Type of Busineor Prope FACILITY ID# SERVIC R ST <br /> s I L� , "3 Z O <br /> OWNER OPERATOR 1 ' <br /> x l_ BILLING PARTY❑ <br /> FACILITY NAME <br /> CJ I <br /> SITE ADDRESS C_ ` <br /> SVe Numbv OireNon � Streel Name ype Sudetl <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE ZIP7C Z <br /> P C#1 — APN# LAND USE APPLICATION# <br /> PHONE#2 ECr. BOB DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> npc �L L BILLING PARTY❑ <br /> BUSINESS NAME PHONE# Exr. <br /> Lues �•, G� - E ��e` ��-s-3oG <br /> MAILING ADDRESS FAX# <br /> CITY / /__ //s / STATFr, ZIP gr77� <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site <br /> I and/or project Specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project Or activity will be billed to <br /> 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 COUNTY <br /> Ordinance Codes, Standards,ST and F =RAL rrA. <br /> APPLICANT SIGNATURE: / DATE: I" le/ — <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT & . <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is require6Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, I, the owner or operator of the property located at the above site address, <br /> hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES ENVIROfNMENTAL HEALTH DIVISION as soon as it Is available and at the same time it is provided t0 me or my representative. <br /> TYPE OF SERVICE REQUESTED: f /_ �I—),/, �,' = S <br /> COMMENTS ❑ SPECIAL CONDI OF APPROVAL El vOTHER <br /> J ❑ <br /> SP1 RS' P9s ..., <br /> JAN 14 1999 <br /> y pSAN JOAQUIN L,Ur <br /> PUBLIC HEALTH SEISEI IS <br /> Sf <br /> ENVIRONMENTAI H <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: DATE: <br /> APPROVEDB ' )/ > �,� �„'!A EMPLOYEE#: �n DATE: <br /> ASSIGNED TO: /�4 (` (�/ � EMPLOYEE#: DATE: <br /> Date Service Completed (if already c pleted): SERVICE CODE: P 1 E: <br /> Fee Amount: Amount Paid oo Payment Date <br /> Payment Type Invoice# Check# „t' y' I Received By: <br />