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SERVICE REQUEST _ <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER OPERATOR BILLING PARTY❑ <br /> FACILITY NAME <br /> SRE ADDRESS41 <br /> (t l Ovse.a xume. 1Mw� I sr«rxan. 'M1d�'� suns <br /> Mailing Address (If Different from Site Address) <br /> Crry STATE ZIP <br /> PHONE91 APN# LANG USE APPLICATIOH# <br /> ( ) <br /> PHONE#2 ter. SOS DISTRICT LOCATgN CODE. <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR r BILLING PARTY❑ <br /> �/at wS <br /> BUSINESS NAME PHONE# �T- <br /> C� (cJl <br /> 1 (201 <br /> MAILING ADDRESS FAx# r/ <br /> )( l�l� I �� tri 1� &Op -30 [ <br /> CITY L,, l STATE Cl+ ZIP 995'2� <br /> z /O <br /> -BILLING ACKNOWLEDGEMENT: I, the undersighed property or business owner,operator or authorized agent of dame, acknowledge that all site and/or Project speaFc <br /> PUBLIC HEALTH SERvicEs EtmROHMENTAL HEALTH ONZION hourly Charges associated WIN this ptojed or aGMily Will be billed to me or my business as idenithed on this form. <br /> I also certify that I have prepared this applio d Nat the work th be per10mled WiE be done in aaardance with all SAN JCAOUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGHATU DATE: I /U U <br /> PROPERTY/BUSINESS OWNER OPERATOR I MrwAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> YAPPuuwr4 rnf the 811ACP. ..91-dcf-JUMAadw to sign u Wdrsd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,i,the owner or operator of the property located at the above sfte address,hereby aunonze the release of <br /> any and all results,geotechnical data ancifor arnaWmentaVsde assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OMSICN as soon <br /> as it is available and at the same time it is provided to me or my reptesentative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> P !40' '``pis •dr <br /> 3 � 00 <br /> .�� N000 /• SAN J,- _ <br /> P41(9 PUBLIr <br /> -IN SPEI:roRSSl�itrATuC r% -3� / FNNPDN'J <br /> r � , /-�/ , — PCarrtRncroR'S sIGruTUR6:— <br /> APPROVED BY: {�1 EMPLOY—aA: DATE: AZ <br /> ASSIGNED TO: V' EM V� C{ DATE: <br /> Date Service Camfeted (if abudy completed): SERv cECoDE S P I E-, to <br /> Fee Amount - S O( Amount Paid Payment Date <br /> Pay„�entType Invoice# Check# Received By: <br /> • �f fl <br />