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4W <br /> 0 SERVICE REQUEST <br /> C <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S�2 CXR s So 4 S3 <br /> OWNER OPERATOR BILLING PARTY❑ <br /> GIm <br /> FACILITY NAME <br /> E <br /> SaE ADDRESS .J r7��► <br /> r 5 1P Street Number Dtrrction {�WASrrMNam� <br /> TYPE SvIU <br /> Mailing Address (If Different from Site Address) <br /> cmr <br /> STATE /j � ZIP <br /> PHONE#'IE.• APN# LAND USE APPt KATION# <br /> ( PSI- P- 2 03 -o oo©3r <br /> PHONE fI2 a0$:DISTRICT LOCATION,?J' <br /> CONTRACTOR/SERVICE REQUESTOR <br /> `� /N <br /> REQUESTOR BILLING PARTY <br /> 151> <br /> BUSINESS NAME � PHONE# Fart. <br /> r <br /> MAILING ADDRESS -Z@�L--T34 <br /> FAX# <br /> CITY 4 <br /> -- STATE /1� - ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business avmer,operator or authorized agent of same,acknowledge 113at all site and/or project specific <br /> PUBLIC HEALTH SERVICES Errv3RONmE NTAL 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 Ord;nanco Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPucANT SIGNATURE: DATE, <br /> i <br /> PROPERTY/BUSINESS OWNER OPERATOR I MANAGER ❑ 0tHERAuTHOR3ZEDAGENT ❑ <br /> i flArPt r wr is not Uw Q�t tvG Arum Proof of aullror;rat/on to sign Is requtrod Titre <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 environmentallsito assessment information to the SAN JOAQUIN COUNTY PUGL3C HEALTH SERVICES ENVIRONMENTAL HEALTH Drws=as soon <br /> as it is available and at the same time it ismvidod la me or <br /> P my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> rr A A19 14A <br /> COMMENTS: 'a' <br /> � Y <br /> r� 6 �alai PAYMENT <br /> �f <br /> RECEIVED <br /> FEg 0 � 2009 <br /> SAN NE ROM <br /> ENTAL <br /> t tEALTM nir>'AA►�tt=rrr <br /> 1 INSPECTOR'S SIGNATURE: <br /> P CONTRACTOR'S SIGNATURE: <br /> !f APPROVED 13Y:, O L t V9 t EMPLOYEE11: 03�f DATE: <br /> l I �- 'f U <br /> ..'ASSIGNED TO: f� EMPLOYEE#r: �3�� DATE: <br /> a :Date Service Completed (if already completed): <br /> SERVICE CODE: S2fC P I E:- > <br /> Fee Amount- j�. p0 Amount Paid �-( <br /> -0 Payment Date �J ,� <br /> I Payment Type ✓ Invoice#' Check# �'� _ f <br /> Received By: 7� <br />