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SERVICE REQUEST y' 3 <br /> Type of Business or Property FACII-n ID# SERVICE R/EQUEST# <br /> OWNER OPERATOR BILLING PARTY❑ <br /> FACILITY NAME <br /> d o ZZIr <br /> i" !n <br /> SrrEAODRESS /� �( <br /> Strep NumOv of OIA,�rH O Type SUNea <br /> Mailing Address&f Differe rom Site AddresS, <br /> Crry q STATE ZIP <br /> PH0NE#1 Fn. rAPN# L1N0 USE APPLICATION# <br /> PHONE#2 FTT SOS Dlstr`T LOCATION CGDE. <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> r s <br /> BUSINESS NAME PHONE# <br /> MAILING ADDRESS Fax# <br /> Q u <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site andlor project speclIc <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HE<Tut ONISION hourly charges associated with this project or activity will be billed to me or my business as identified cn this forth. <br /> I also certify that I have prepared this application and that Ne•vork to he performed will be done in accordance with at SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. / <br /> APPLICANT SIGNATURE: ADATE: `l �' 191� <br /> PROPERTY/BUSINESS OWNER C OPERATOR I MANAGER ❑ OTHERAIRHORIIEDAGFM 0 <br /> IIAPPr !Snout*&rr*.c PArrry proof ofaudiormfton bsgn is rsquvad rifle <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 emimnmentailSite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OrvISION 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 /> COCOMMENTS: •{I�eviCL. ) FC-- for .�i./ �y��Lbirify - �liT►'�i �4 /ay <br /> APR 10 <br /> Ir <br /> INSPECTORS SIGNATOR C CON[RACTOR$SIGRATLR <br /> APPROVED BY: EUPLCYr#: ,� DATE <br /> ASSIGNFDT - vp,• 60 EMPLOYEE#: DATE O �Z <br /> Date Service Completed ('d all ady completed): - SERVIOECODE: <br /> Fee Amount wAmount Paid Payment Date y.. Z' <br /> Payment Type �. <br /> Invoice Check# 3-55 23-73 Received By: <br /> -1/.3 6D "",� <br />