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SERVICE REQUEST <br /> Type of Business or Property FP.CILITY ID# SERVICE REQUEST# <br /> OWNER OPERATOR BILLING PA`15 <br /> 12�r esti bf"�4 � v <br /> FACILITY NAME <br /> SITE ADDRESS `tf r <br /> 0\`-�Str�H NumbH grection SVM Nxnr Tyr. S.K. <br /> Mailing Address (If Different from Site Address) <br /> CITY CC)t0LLL� STATE 7u, <br /> PHONE#1 IEr. APN# LAND USE APPLICATION <br /> - <br /> PHONE#2 BOSDmRICT LOCATgNCODE _ <br /> CONTRACTOR/SERVICE REQUE//S��TOR ,. /� I ' n I— <br /> REQUESTOR l '�i ' � �� Som ���• /,oUII,C W•U1L✓ \ BILLING PARTY <br /> BUSINESS NAME `Y ,/V �V 1/-// PHONE# Fsr. <br /> y l O, ( , �n t- vis Svc . 1 v� 7-376 <br /> MAILING ADDRESS �2 FAx# <br /> c/ Kl Nr�U 5�G�1 Lv-,, '] /'� f 010 _ b 30 <br /> CRLY O C9 ; \{� L Sa`�CD STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the-un`dersgned property or business owner,operator or authorized agent of same, acknowledge that all site andJor project spedfc <br /> PUDLIC 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] E DATE:C;� <br /> PROPERTY BUSINESS OWNER ❑ OPERATOR MANAGER el� OTHERAUTHORVEDAGENT 7 <br /> If APPLcwrisnNtrtiAn <br /> ea . Path Proodod authorhadon to sign is raqulrod Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner oropemtorof the property located at the above site address,hereby authorize the release of <br /> any and all results,geolechnical data and/or environmentatsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DmsION as soon <br /> as it is available and al the same lime it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: s <br /> COMMENTS: <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: U EMPLOYEE#: DATE: <br /> ASSIGNED TO: ��[� EMPLOYEE#: �� �L'7 DATE: <br /> .Date Service Completed (if already completed): ., - SERVICECooE: ZZ :P j E: � <br /> Fee Amount: �� Amount Paid ( Payment Date R I,, <br /> Payment Type Invoice#' Check# ,.--, Received By:- <br />