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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS I <br /> Numbe► 91 tion Tvve Shite A <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 3 ---- <br /> CI1Y STATE �r� -- ZIP _ <br /> PHONE#� Exr. APN# LAND USE APPLIC TION 1i <br /> LPHOIE2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE 9 E.I. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY Ivfe a��� STATE ZIP �� ( / <br /> BILLING ACKNOWI.EDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific PUBLIC HEALrii SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges <br /> 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 applica ' and that it ork to be perfixnTed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinalrce Codes,Standards, Sr d FFne L ws <br /> aPPL[CAy 1"S SIGNATURE: DATE: 1 <br /> PROPERTY/ BusINESS OWNER OPERATOR/I ANAGER ( 1FI . ITIITIRIZED AGENT <br /> !f.d PPLICINT iS nor rhe BILLING P:I RTY,proof of artfl oriLaf. I Title <br /> AIJTIIORIZATION TO RFLEASF, INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY PUBLIC HEALTH Sl--.RVI(-ES ENVIRONMLNTAI. HEALTH DIVISION as soon as It is available and <br /> at the same time it is provided to me or my representative. p� / rte/ <br /> TYPE OF SERVICE REQUESTED: SO�L }L�/Tf(c3/L/T� �����C /��V(�" " art <br /> PA <br /> COMMENTS: r^^ A <br /> nm <br /> rw,w 4'O <br /> SAT:Jur.C)IJiN w N lw <br /> PUBLIC HEALTH SER VIM <br /> EIJVIRONMENTAL HEALPI-0111t (0#4 <br /> INSPECTORS SIGNATURE: IY <br /> CONTRACTOR'S SIGNATURE: -- _ - <br /> APPROVED BY EMPLOYEE# ' DATE: ] t� <br /> ASSIGNED TO: EMPLOYEE#: / :4DATE: <br /> SERVICE CODE: '�!DJP 1 E:Date Service Completed (if already r mpleted):Fee Amount: G T��� Amount Paid c ���.pQPayment Dato y 9 <br /> Payment Type -I CY I Receipt# Check At Received By. ' <br /> 7/1/1999 <br /> SRRF')rcV doc <br />