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SERVICE REQUEST <br /> i ype of Business or Property FACILITY ID# SERVICE REQUEST# <br /> NER f OPERATOR D BILLING PARTY 0 <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction !/ /r- Sum <br /> TYOe Suite/ <br /> Mailing Address (If Different fro Site Addr SI <br /> came' l� <br /> CITYIO�� STATE /,/J ZIP <br /> v C /� 9�/Z <br /> PHONE#'I Exr• APN# LAND USE APPLICATION# <br /> I 4L - 5 <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR BILLING PAR�y <br /> BUSINESS NAME PHONE UT. <br /> # <br /> �'co`' zcr 2--31-1-375 <br /> MAILING ADDRESS <br /> S 3FAX# <br /> 55 -S/pri �clil <br /> CITY ` / O/� STATE 1,— 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 to me or my business as identified on this form. <br /> I also certity 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, c� <br /> APPLICANT SIGNATURE: DATE: Z— <br /> PROPERTY/BUSINESS OWNER O PERATOR/MMAGER O OTIIERAUTHORIZED AGENT A <br /> I(APPc c wr is not the UI LING Party 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 environmentallsite 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: <br /> COMMENTS: <br /> 1( 1 ;Iy r;r ate, �e�i cm �r / <br /> a—/A 7 Y4d"IV <br /> �� s� S.,3v �-�=✓ 2,�� � �� s...� DEC 2 s <br /> '�"�s,e6 z . s sem/ J J I� <br /> ,,J 5 r'r a SAN JOAQUIN COUNCY <br /> <:Z-7o r 1 /�� PUBLIC HEALTH SERVICES <br /> c+ J'1 ENVIRONMENTAL HEALTH DIVISa <br /> It. <br /> INSPECTOR'S SIGNATURE: /�`le 'L�� s/` b�Q xQ� 7 <br /> / t CONTRACTOR'S SIGNATURE: �J <br /> APPROVED BY:. EMPLOYEE#: <br /> Ott__) DATE: <br /> ASSIGNED TO: �r Q EMPLOYEE#: WDATE:Date Service Completed (if already completed): ?o o - �C( SERVICE CP!E: <br /> Fec Amount: v7AI ` \Amount Paid5PaymentType Invoice#' Check# 7/fir' d By: <br /> ­174 <br />