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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> ILII <br /> OWNER/ OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE DRESS <br /> / Street Number Direction Street Name Suite z <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> CITY —�( +z_NSTATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ?/ CHECK If BILLING ADDRESS <br /> pig f YI�S'St?'h- <br /> IBUSINESS NAME / : / n I PHONE# EXT. <br /> HOME Or MAILING ADDRESS rzeN FAX# <br /> CITY ( / STATE CA <br /> ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific PUBLIC HEALTH 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE:} v DATE: <br /> PROPERTY/BUSINESS OWNER 47-OPE OR/MANAGER OTHER AUTHORIZED AGENT _ <br /> If APPLICANT is not the BILLING P.IRTY 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 <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 SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and <br /> at;he same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: qbl l) ol1 ok.! <br /> COMMENTS: <br /> AUG 6 J Wk,. <br /> SAN JUAUUiN UUUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: r CONTRACTOR's SIGNATURE: <br /> APPROVED BY: EMPLOYEE#: r"` � 1 DATE: <br /> AsSIG?OED TO: r ( EMPLOYEE f: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ?/E: <br /> Fee Amount: ^� U Amount Paid Payment Date <br /> Payment Type Receipt# I Check # Received By: r 1 <br /> a. <br /> S-9-y9 - 30,x, .►�� <br /> SRREQrev.doc 2, ✓!u 7/1/1999 <br /> 8 -31-gq qurn1h -5-rP+-- V -5-1 wat.�Yr.i �1a.� � ts'i►LA4MQ/[•.S; _ <br />