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s <br /> SERVICE REQUEST <br /> Type of Business or Property FACILfIY ID# SERVICE REQUEST# <br /> i <br /> 011'lNER J OPERATOR <br /> ! BILLING PART(❑ <br /> FACIIJTY NAME <br /> W <br /> SITE ADDREc�, 6 <br /> f 7 StrrN i{umbor e ( 7WT , sWN Mem rYP11 svlh f <br /> Mailing Address (If Different from Site Address) <br /> CJYY STATE zip <br /> PHONE#'t EXT. APN# LAND USP _TION# <br /> ( 0� <br /> PHONE#2 T• BOS DISTRrr LOCATION CODE' <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTQR <br /> BB UNG PARTYA <br /> BUSINESS KAME <br /> PHONE# Ext. <br /> .t'.x� <br /> MAILING ADDRESS FAX# <br /> CITY +J� STATE � zip <br /> BILLING ACKNOWLEDGEMENT: 1, 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❑MSION hourly charges associated with this project or activity will be billed to me or my business as identified on this form. <br /> I also certify that k have prep this app' tion and Ihat the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> )APPLICANT SIGNATURE KATIE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATORI MANAGER ❑ OTHER AUTHORtZED AGENT ❑ <br /> YAPvl i orris not the DUtaEurry proof of authorization to sign Is requimd Fitts <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,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 and/or environmentaUsite assessment information to the SAN JOAOUIN COUNTY PUBUC HEALTH SERVICES EN%nRoNMENTAL 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: <br /> COMMENTS: <br /> PAYME14T <br /> R EC EMD <br /> APR 1 420 <br /> SAN jOAQUIN COUNTY <br /> ,rUBUC MEALTH SIE VIUE5 <br /> EWiROXMENrAL',F1EA13-I L VISION <br /> INSPECTOR"S SIG14ATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVEDBY:. EMPLOYEE#: CJ DATE: <br /> ASSIGNED-TQ: EMPLOYEE#: <br /> DATE: <br /> Date Service Completed (if already completed): � SERwCECopE. <br /> 00,Q., —E5 P1E:.,:Z60 2,: <br /> O ' <br /> Fee Amount; o � Amount Paid c� <br /> t �D-� Payment Date y I q <br /> Payment Type ✓ Invoice f{' Check# <br /> Received 8y:`� <br />