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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE RE77QUEST# <br /> OWNER I OPERATOR BIWNG PARTY❑ <br /> FACILITY NAME J <br /> r <br /> SrrEADORESS <br /> AL T. <br /> T. Sun.e <br /> Mailing Add ifferentfrom SI <br /> Cm _�j STATE 7.P <br /> PHON 1 - A LAND Us APPLICATION# , <br /> PHONE#2 dT BOS DISiTtICT - LOCATION CODE. - <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> BUSINESS NAME PHONE ` �T <br /> ,1G � _ ';24r4 <br /> MAILING ADDRESS j � /_ FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site andfor project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with the pmjeG a 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 thatthe Ik to mTed will be in aordance with ad SUN JOAQUIN COUNTY Ordinance CodeS,Standards,STATE and <br /> FEDERAL laws. <br /> {' <br /> APPLICANT SIGNATURE: '. / � w <br /> DATE: <br /> PROPERTY I BUSINESS O'ANER OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT O <br /> If APgcum a nor axr 61,MP)OTY.prod of wif"tndon b sign isrpuind Two <br /> AUTHORIZATION TO RELEASE INFORMATION:When appltcable,I,the owner or operator of the property bated at Me above site address,hereby authorize the release of <br /> any and all results,geotechnical data antll0r amimnm%IIal(Site assessment information W the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES EWRONMErrrAL HEALTH OMSION as soon <br /> w A is available and at this same time it is provided W me or my representative. <br /> TYPE OF SERVICE REQUESTED: fQ_ vv-l�l r <br /> /r <br /> COMMENTS: <br /> � <br /> ' <br /> INSPECTOR'S SIGNATURE: CONTRACiO SSIGNATURE: <br /> APPROVEDBY: �`j EMPLQYEEA: DATE: ..-� <br /> ASSIGNED TO: �Ll.yr EMPLOYEE#: DATE: }-- <br /> Date Service Completed (ff already completed): SERVICECOOE: 6 `/ P I Ec ;Z�, 101* <br /> Fee Amount / 7f Amount Paid Payment Date <br /> Payment Type Invoice Check# Received By: <br />