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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR BILLING PARTY❑ <br /> FACILITY NAME <br /> SITE ADDRESS /AP /av <br /> StreetNumber Direction /L ` Street Name FTYP" Suite 0 <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT --FLOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> QIJESTOR _ BILLING PARTY <br /> ��L ALi <br /> BUSINESS NAME PHONE# r- EXT. <br /> MAILING ADDRESS FAX# <br /> CITY �j /jSTATE,,- i1 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 t0 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: Yyz�r^ DATE: Z <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> It APPLcmr is riot the&LyNc PA rrr,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,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentalisite 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: Alit <br /> r -s <br /> COMMENTS: <br /> rll ¢��i 6V1Ci`� 1 <br /> FEB 2 8 2000 <br /> SAN JOACUM COUMY <br /> PUBLIC HEALTH SERVICES <br /> dVt!?'JNtvtENTAL NEALTSl 1!1,91+"* <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: � EMPLOYEE#: Wo C DATE: <br /> Date Service Completed (if already completed): 3 SERVICE CODE: <br /> Fee Amount: U Amount Paid13U / Payment Date <br /> Payment Type ` Invoice#* Check# Received By: <br />