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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> r I A- <br /> `5— . <br /> OWNERIOPERATOR BILLING PARTY <br /> ^ S <br /> FACiLn NAME <br /> SLCc <br /> SREADDRESS ,� ( 3'} S ?�}-rrL �j�.� cjl <br /> Straat Num(rr IietVon SVM TTOa Svltal <br /> Mailing Address (If Different from Site Address) <br /> CRY STATE ZIPc <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (' ✓A gSL - S — I <br /> PHONE#Z On. BOS DISTRICT LOCATION COOE <br /> • CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> ; ) BILLING PARrYZ <br /> BUSINESS NAME PHONE# Fzr. <br /> MAILING ADDRES FAx# <br /> lo" <br /> Crry r% STATE zip <br /> BILLING ACKNOWLEDGEMENT: I, the Undersigned property or business owner,operator or authorized agent of same, acknowledge that all site andlor project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DMSION hourly charges associated wilt this project or activity will be billed to me or my business a;,identified on N4 form. <br /> I also certify that I hav:prohoa this application and Nal thework to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards•STATE and <br /> FEDERAL Laws. <br /> APPucANT SIGNATUREvy / � � �� DATE:PROPERTY I BUSINESS ❑ OPERATOR/MANAGER ❑ OnIER AUTHORIZED AGENT ❑ <br /> IIArM vrisnotgn Dune PuRr proof ofauthodndon to sign Is rvqufrvd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.1.the owner or operatorof 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 Ne SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it u available and at the same lime it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: rr r' <br /> SD f <br /> COMMENTS: / / / � <br /> AA DI — `7 /o 11 <br /> ( I(�,� '.' / AYMEN <br /> J / M�ECEI'✓Gi - <br /> ==.moi <br /> ��iTURE�'�",y/ <br /> INSPECTORS SIG 1URNIl E: 3 O.�A"+.+1G CO CTOR'S SIGNATURE: <br /> APPROVED BYL EMPLOYEE#: O/ // DATE: <br /> ASSIGNED TO: L' rl EMPLOYEE 4: �5- DATE: <br /> Dale Service Completed (if already completed): `L/ SERVICECODE: C P I E: <br /> � . <br /> Fee Amount: �� Ia Amount Paid - r—J <br /> j Payment Date <br /> 1-2 S 6 t <br /> Payment Type - .1 <br /> Invoice#' Check 9 Received By: <br />