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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> BILLING PARTY❑ <br /> FAciLm NAME <br /> SITE ADDRESS <br /> Strut Number Dlre�n v v �rNt�� Type Sults <br /> Mailing Address (if Different from Site Address) <br /> CITY STATE Zip <br /> PHONE 91 APN# LAND USE APPLICATION# <br /> PHONE#2 Eu. BOS DISTRICT l oCATIOH CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR BIWNG PARTY 0 <br /> BUSINESS NAME ^� PHONE# EXT. <br /> MAILING ADDRESS FAX# <br /> Zz 5L,),.; LEES( P[�i�E z Z3`,- 8 3q <br /> CITY A 1 . STATE ZIP g53 3-7 <br /> ING 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 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: DATE: <br /> AROPERTY/BUSINESS OWNER (] OPERATOR/MANAGER 8 OTIIER AUTHORIZED AGENT O <br /> If APPUGWr.s not U)o QgLMG Pni+rY proof of authorization to sign is requirod Tit 1 e <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,geolechnical data and/or environmental/site assessment information to U+e SAN JOAQUIN COUNTY PUaUC 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 /> S �� � ; ( � S�t�•�1 <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVED <br /> :2-1 0 2,0 �2_ SEP 1 0 2001 <br /> SAN JOAGI.'IN COU:d iY <br /> PUBLIC HEALTH SER'diCE <br /> FNVIRONMENTAI HF,'`r <br /> INSPECTORS SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. I # <br /> EMPLOYEE : ��ll <br /> DATE: G <br /> ASSIGNED TO: EMPLOYEE#: —�7 L' DATE: <br /> Date Service Completed (if already completed): SERVICECODE: �) -� P1E:.;2&6 <br /> Fee Amount: l Amount Paid 14 C�—+ ov CO_a�— Payment Date q I O r o <br /> 1 I <br /> Payment Type CA2Ja4 Invoice#• Check <br /> `I Received By <br />