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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# <br /> SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> /J <br /> rBILLING PARTY❑ <br /> �Of� 6,c,i,l a�-f.v 1� /�—{�<<�2 �j C',L�Cl"� <br /> FACILITY NAME <br /> SITE ADDRESS 7 r C r <br /> 5; t4tJY` <br /> strut Number Direction Strw Name <br /> Mailing Address (If Different f om Site Address) (/ TrP• sorh.. <br /> CI1110 TY ('J1"—' L /¢�/ Z/ <br /> O <br /> Le Q STATE /) ZIP _ <br /> PHONE 91 (f/•�— z L/ <br /> r'rT• APN# LAND USE APPLICATION# <br /> ( ) <br /> _] <br /> PHONE#2 BOS DISTRICT LOCATION CODE <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR BIWNG PARTY f] <br /> A) FIT t— if�� <br /> BUSINESS NAME PHONE# <br /> MAILING ADDRESS FAX# D <br /> Crnr �•7—jL_-/J <br /> STATE i k ZIP C�—zv s C <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or projectspecific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DiviSION hourly cha -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 cation and that th be pe ed will be done in accordance with all SAN JOAQU;,14 COUNTY ondianca 9des.Standards,STATE and <br /> FEDERAL laws. ! <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWPIER 0 OPE TOR/MANAGER 0 OTHERAUTHORIZED AGENT O <br /> 11 APR r wr is not the Ou/?;G PAmv proof of authorization to sign Is required Tit 1 o <br /> AUTHORIZATION TO RELEASE INFORMATION.When applicable,I,tie 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 environmentaVsite a5SCS5menl information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMEHTAL HEALTH DIVUiON as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUEST£'t7: <br /> COMMENTS: wCJ <br /> Al <br /> T T-A0 <br /> —Li/zu � <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S IG A E: <br /> APPROVED BY:. / V / EMPLOYEE#: �( �7 DATE: <br /> ASSIGtIEDTO: EMPLOYEE#: DLl DATE: <br /> Date Seryice Completed (if already completed): .;.. $ERVICECooe: P!E: <br /> S 2S 26,62 <br /> Fee Amount: L( Amount Paid 445' Payment Date <br /> I <br /> Pl ayment 1it•ype Invoice • Check# Z rJ b Received By: �_ <br />