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f t SERVICE REQUEST . <br /> L <br /> Business or Property FACILITY ID ft SERVICE REQUESTOPERATOR CBILLING PARTY❑ <br /> NAME � aRESS <br /> Strar NYTEr Dlrallon Q ma T1oa Suiba <br /> t Mailing Address (11 Different from Site Address) <br /> COY STATE (1/i— <br /> ZIP <br /> PHONE#1 APN# LAND USE APPLICATION S <br /> ( <br /> PHONE#2 - En. 130S DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REDNFSTOR BILLING PARTY <br /> BUSINESS NAME h PHONE If 6 <br /> MAILING ADDRESSr C, FAX a <br /> i ZC l o0 <br /> I CRY STATE zip 6� C'^ <br /> J <br /> BILLING ACKNOWLEDGEMENT: I. the undersgned property or business owner, operator or authorized agent of some, acknowledge that all site and/or project specific <br /> 11pp PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to me or my business as identified on this form. <br /> { 1 also certlly that I have prepared this afinlication and that the work 1 ormed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes.Standards,STATE and <br /> I` FEDERAL Iav1S. (_ C� <br /> APPLICANT SIGNATURE: DATE: S _ I Z— ( 9 _ <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/MANAGER O OTHER AUTHORIZED AGENT ❑ r <br /> NAPPL. rlsndtlwi)l Purv.paofofaudiortradontoslenhnqukvd Tills <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 environmenlatsile assessment Into motion to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as Soon <br /> as II is available and at the same time II is provided.to me or my represented". <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: p� <br /> PAytl MENT <br /> MAY 121 9 <br /> BAN PUBUG HEA TiH 6E+RJNN <br /> Iq R <br /> ENVIRONMENTAL HEALTH DIVISibh•, <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S.SIGNATURE: <br /> APPROVED BY: �. EYPLOYEECxZ 1 DATE: 5 z <br /> ASSIGNED TO: <br /> EMPLOYEE#: IIL•L/ DATE: <br /> Date Service Completed (If already co leted(: SERVICE CODE: a I P/E: p� <br /> 1 1q <br /> Fee Amount: .Q () - Amount Paid �90-� Payment Dale <br /> z <br /> Payment Type Invoice p Check A 6dJ 383 Received Byr <br /> I <br />