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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> BILUNG PARTY❑ <br /> O <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name Type Suite <br /> Mailing Address (If Different from Site Address) <br /> , . <br /> CITY <br /> 2 0 4 0 5 STATE ZIP <br /> L� G � 33� <br /> PHONE#1 Eul• APN# <br /> ( ) LAND USE AP ON# <br /> ;:2-q-3- .�30-oZ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR BILUNG PARTY❑ <br /> BUSINESS NAME PHONE# IxT. <br /> u G c� mert.f <br /> MAILING ADDRESS FAX# <br /> � T <br /> CITY ( <br /> F -..a 4 STATE A zip 3 <br /> BILLING ACKNCWLEDGEMENT: 1, 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 DNISION hourly charges associated with this project or activity will be billed to me or my business as identified on this form. <br /> 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. U <br /> APPLCANT SIGNATURE: (T V DATE:_[ <br /> / I L <br /> PROPEitTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> if APPLCANT is not the BILLING PAarv,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 al: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: ( i � <br /> 1\ i5-4 <br /> COMMENTS: <br /> q� — 9 /— P <br /> EC-" Vf:D <br /> c9f- � NOV 241699 <br /> '1-41.i✓tu CIUIN(:r)JN;Tr <br /> Z b2 _ �S( . PL,iUC HEALTH SERVICES <br /> U / ENVIRONMENTAL HEALTH UiV?SION <br /> INSPECTOR' SIGNATUr'E: CONTRACTORS SIGNATURE: <br /> APPROVED BY: V EMPLOYEE#: 0 / DATE. <br /> ASSIGNED TO: EMPLOYEE#: �6 DATE: <br /> Date Service Completed (if alr ady completed): SERVICE CODE: 522— P I E: Y-2 -0 ! <br /> Fee Amount: S` 0� Amount Paid Payment Date C <br /> Payment Type Invoice#' Check# Received By: <br /> A-2/.2 7/7 yD m f h <br />