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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#���� <br /> jl 1 <br /> OSI OPERATOR BILLING PARTY <br /> e., <br /> FACILITY NAME / <br /> SITE ADDRESSC-d <br /> umber OOirection V Stmeet`N+ame T e I Suite <br /> Mailig Address (If Different from Site Address) <br /> / 7 1 5� Sri <br /> ITY r STAT ZIP <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> PHONE#2 BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> BU E� AME � r PHONE# � —��/ <br /> Cl d <br /> MAILINDRESS ` FAX# <br /> C ITV / / SATE P <br /> BILLING ACKNOWLEDGEMENT: I, 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 DIVISION 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 I have prepared this application and that 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: DATE: <br /> PROPERTY/BUSINESS OWNER _ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> if APPLICANT is not the BdLNc PARK,Proof of authorization to sign is required 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,geotechnical data and/or environmentaVsite assessment information to the SAN JoAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL 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: 7 <br /> PAYMENT <br /> RECERT <br /> AUG 111998 <br /> SAN JOAQUIN CUUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISIOn, <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: i I EMPL^YSE#: / (/ DATE:Z e7 <br /> ASSIGNED TO: EMPLOYEE#: 12 V(� DATE: <br /> Date Service Completed (if already completed): . 2 SERVICE CODE: PIE: (� <br /> Fee Amou ,G,G Amount Pa' G Payment Date 'J <br /> Payment Type Invoice# Check# � Received By: <br />