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SERVICE REQUEST EH0061SR revised 97110/98 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> o <br /> OWNER OPERA ✓' <br /> I �i r \ BILLING PARTY El <br /> FACILITY NAME <br /> SITE ADDRESS 11`� t� <br /> Street Number L. (�{J f Type SudeA <br /> Mailing Address (if Different from Site Address) ,1 Q <br /> �{ <br /> CRY \l STATE CA <br /> zipcm <br /> �[ <br /> Q�#1 ETT. APN# LAND USE APPLICATION If !' <br /> PHONE#2 Exr. BOS DISTRICT LQQATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR ^ I BILLING PARTY <br /> eJ <br /> BUSINESS NAME PHONE# ^ Exr. <br /> L n L <br /> MAILING ADDRESS FAx# <br /> Q"i <br /> CRY ` STATE C/ 1 zip S5 <br /> N^.4 KNOWLEDGEMENT: I the unE,jAtG�ER <br /> erty or business owner, operator or authorized agent of same, acknowledge that all site <br /> andlor pro ecific PUBLIC H LTH SEMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to <br /> me or my busine iden'le on this <br /> I also certify that I have a hi that the work to be performed will be done in accordance th all SAN JOAQUIN COUNTY <br /> Ordinance Codes, Standa s, TAT <br /> APPLICANT SIGNATURE: DATE: yi <br /> PROPERTY BUSINESS CANE ❑ AGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICANTis not fhe BILLING TY 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: <br /> COMMENTS ❑ SPECIAL CONDrrIONN(QS)_OF APPROVAL❑ OTHER 1,�` ❑ <br /> �-� 117ENI <br /> JAN 12 1999 <br /> ENVIPUBLIO HEq TN c; � <br /> EALTH DNIS)pl <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: ' DATE: <br /> I I <br /> APPROVED BY: EMPLOYEE III: lo ' DATE �Z g <br /> ASSIGNED TO: S EMPLOYEE#: V( OZ DATE: Z <br /> Date Service Completed (if alre y completed): SERVICE CODE: a P/E: <br /> Fee Amount 3'�O___, 1Amount Paid -2,q t7 Payment Date I 1 1a 19 9 2 <br /> Payment Type ,/ Invoice# Check 9 �j 4,!547Received By: <br />