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SERVICE REQUEST <br /> Tvpe of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR BILLING PARTY IJ <br /> FACILITY NAME <br /> SITE ADDRESS (��7�Y,��� '�'� t� Vic, a� <br /> r AD StreetTlumbar DI ( �'] tJ—� iz,%.Name Type Suite# <br /> Mailing Address (if Different from Site Address) <br /> ZfQ1�` A PpLr-- C '<O /Z <br /> CITY STATE zip <br /> STS%�- '-1.1 C fi 2c <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY C <br /> Vin! LiL t. c7-OV-71:5 <br /> BUSINESS NAME PHONE EXT. <br /> MAILING ADDRESS FAX# <br /> CITY ( STAT zIP <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: ` c L�/,! �� DATE: <br /> PROPERTY/BUSINESS OWNER C. OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the B2UNG PARTY,proof of authorization to sign is requi 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,geotecnnical data and/or environmentaYsite 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 it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: .. + <br /> COMMENTS: <br /> PAYMENT <br /> i <br /> RECEIVED <br /> JUL 2 4 1998 <br /> SAN JOAQUIN COUNTY <br /> PUBUC TH SERVICES <br /> ENVIRONMENTAtLHEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EMPLOYEE#: j <br /> O ( DATE: � <br /> ASSIGNED TO: EMPLOYEEM ' DATE: L <br /> Date Service Completed (if already completed): SERVICE CODE: 5 P/E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type y I - I [a I <br /> Invoice# Check# Received By: <br />