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SERVICE REQUEST EH0061SR revised 07/10/98 <br /> Type of Businesso Propel FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR (�/ <br /> BILLING PARTY❑ <br /> FACILITY NAME C <br /> SrTEADDRE S <br /> (<7 <br /> Mailing Address (If Different from Site Address) <br /> CITY / / STATE ZIP <br /> PHONE#1 U Ex* APNW LAND USE APPLICATION If <br /> PHONE#2 Fxr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR <br /> /�/ ry BIWRTY <br /> NG PAM <br /> BUSINESS NAME <_, l/Y` O # V U l g o 3 <br /> MAILING ADDRESS / FA%# <br /> CITY STATE ZIP C <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all she <br /> and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL.HEALTH DIVISION hourly charges associated with this project or activity will be billed to <br /> 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 <br /> Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> I(APPUcANT is not the BILLING PARTY 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, <br /> hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: L <br /> COMMENTS ❑ SPECIAL CONDITION(S)OF APPROVAL❑ OTHER ❑ <br /> AYMENJ <br /> REt %;:1%1F:R <br /> JAN 2 5 1999 <br /> SAN JOAQUIN COtrNTy <br /> rol"IPUBLIC I{ <br /> INSPECTOR'S SIGNATURE: CONTRACTORS SIGNATURE: -1-11�11AL HEALTH DIVISi(, 1 DATE: <br /> APPROVED BY: EMPLOYEE#: `�or �j'. DATE: ,C <br /> ASSIGNED TO: 1 r EMPLOYEE#: / ' DATE: 2 <br /> Date Service Completed (if already completed): SERVICE CODE: "' PIE: <br /> 2 S <br /> Fee Amount: '� ® a U Amount Paid x.390. D U Payment Date d-5 9 <br /> Payment Type ✓ Invoice# Check# OD 33 32 1 Received By: <br />