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SERVICE REQUEST 5 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST 9/ <br /> OWNER I OPERATOR �J .�f✓a <br /> V V` �1 BILUwc PnkTY <br /> FACILITY NAME <br /> Sn rbc ac,tlS <br /> SITEADORESS f f0 I <br /> Gg0)c.i <br /> to Number Direction SVM Name <br /> Mailing Address (If Different from Site Address) - TyPe sine r <br /> CITY i <br /> 1. e STATE ,^ ZIP IS_37 <br /> PHONE#'I W. APN# LANG USE APPIJCATIOII# <br /> PHONE#2� 80SDISTRICT LOCA7)ON.CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR , BILLING PARTyY <br /> 0 Avy),0% V10 aLAU U_ <br /> BUSINESS NAME , ^ PHONE 9 Exi. <br /> MAILING ADDRESS _ I,> <br /> Fax# , `'� �-�• __��� <br /> CITY STATE ZIP L <br /> l <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project specirr <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DrvisloN hourly charges associated with this project or activity will be billed to me or my business as identified on LMS 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 /> APPLICANTSIGRATURE:_Y_� ��> ,ice (' ( LV•P�il C,IDATE: t 7 <br /> PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER O OTHER AUTHORIZED AGENT (• )Y 4t 110 rq— <br /> II APRUC-WT is not fhe ftLm Mry proof of authorization to sign is requirod 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,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY PUDUC 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 /> "OIL <br /> COMMENTS: <br /> "jNO a r <br /> . � � <br /> CYuk (S 0 C V14cx(76! QP�Gti <br /> PA-— on z .'j <br /> IN iPEC OR'S SIGNATURE: <br /> ONTRACTOWS SIGHATUR f7D SQ�g�� <br /> APPROVED BY:. EMPLOYEE#: ( (� DATE: <br /> AsSIGNED•TO: EMPLOYEE#: DATE: Q��/ [� <br /> Date Service Completed (if already completed): SERVICECooE: <br /> PIE: <br /> Fee Amount: G Amount Paid r ; <br /> Payment Date <br /> Payment Type Invoice 9' Check# <br /> Received By: <br />