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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S <br /> 01&(.,,07 <br /> OWNER/OPERATOR A BILLING PARTY jI? <br /> FACILITY NAME <br /> SITE ADDRESS y� <br /> E-0 Street Number Irection 0, f treat Name t 1� Type Suite# <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE ZIP <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> (zen 3 3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> BUSINESS NAME , PHONE# EXT. <br /> MAILING ADDRESS FAX# <br /> i s 2 a6l) f — z <br /> CrrY STATE (,O_ <br /> ZIP Z <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 ApPuc wr is not the AI ARry 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 itisprovided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: /— •� ` �, <br /> COMMENTS: 7 1 <br /> PAYMENT <br /> RFIP�11=1i1!pn <br /> AUG 18 1998 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EMPLOYEE#: DATF: 1� <br /> ASSIGNED TO: f X EMPLOYEE#: r-076 <br /> 7"!76 DATE: —F/--((� <br /> Date Service Completed (if already completed): SERVICE CODE: 57-)--?— <br /> P 1 E:. 2-C/ <br /> Fee Amount: vU Amount aid � Payment Date <br /> Payment Type Invoice# Check# Received By: <br />