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SERVICE REQUEST <br /> ..[r <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S�4p SLP� <br /> OWNER I OPERATOR BILLING PARTY O <br /> I <br /> FACILITY NAME <br /> SITEAD�P�5 //j <br /> StmtNumber rection / " G N v1 Type sullen <br /> Mailing Address (if Different from Site Address) <br /> �n <br /> CrIY STATE ZIP �� Q <br /> (��c <br /> PHONE#1T• APN# APCATION#tW <br /> PHONE#.2 BO&DISTRICT LOCATION CODE <br /> CONTRACTOR l SERVICE REQUESTOR <br /> REauESTOR B=XG PARTY <br /> �� c= <br /> HUI <br /> BUSINESSNAJKE ,l I A PH� # Err. <br /> f MAILING AggRE �� r EFAX <br /> � L4-072-3 <br /> r C(TY �� STATE zip <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned prop"or business owner,operator or authorized agent of same, acknowledge Uml allsiteandlor project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OmsicN hourly charges associated with this projector 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 JOAOUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> t` ( �U <br /> APPtJCANT SIGNATURE: DATE: <br /> PROPERTY/BUSINESSOWNER t] OPERATORIMMAGER C] OTNERAUTHORIZEDAGENT 0 <br /> IIMPt,rawris not Tho O Lrc pMfY,proof of authorixatlon to sign Is requhvd Titio <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 environmentallsile assessment information to the SAN JOAOUIN COUNTY Pumic HEALTH SERmcs ENVIRONMENTAL HEALTH DIvisiCn as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUE57,D: <br /> , <br /> COMMENTS: ,SL) I` L�I/ �-p6e1 PAYM E <br /> N i _ <br /> RECEIVED <br /> 2001 <br /> JUL 2; <br /> SAN JC1)U t.i COUNTY <br /> PUBLIC HEALTH�EPVICES <br /> i CNV )NO. f4TAt riFAITN <br /> INSPECTORS SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. EMPLOYEE#: (OO DATE: <br /> 'ASSIGNED-TO: t EMPLOYEE 9- �] C�S DATE: <br /> Date Service Completed (if already completed): L ✓ SERVICE CODE: �� P I E: <br /> FReAmount: Amount Paid � `� Payment Date � j 1e Invoice#' Check# !all 81 . Received By: 1,6- <br /> bo M lg' <br /> � � r♦ <br /> I <br />