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SERVICE REQUEST <br /> Type of Business or Property FACILF Y IDK SERVICE REQUEST <br /> R K <br /> IP- <br /> OWNER/OPERATOR ' f BILLING PARTE❑ <br /> FACILITY <br /> �pNAME <br /> SIT 1 SUeet Number Direction I �V�l�' `'� N�meV <br /> Typ• Suite: <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE Z <br /> PHONE#1 EXT. APN rt LAND USE APPLICATION# <br /> PHONE#2 Ems• BOS DISTRICT LOcATioN CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> RE STOR BIwNG PARTY� <br /> Q E <br /> _FYI <br /> BUSIN s5 NAME PHONE# Err. <br /> MAILING ADDRESS <br /> G' <br /> CITY STATE 1 ZIP L C7--)BILLING ACKNOWLEDGEMENT: I, the unde igned property or business owner,operator or authorized agent of same, ackncxledge that all site andlor project spedfc <br /> Pusuc HEALTH SERVICES EN IRCNMENTAL HEALTH D s*N hourty charg associa with this project or activity will be billed to me or my business as identified on this form. <br /> I <br /> I also certify that I have prepa th s application an that the work to performed ill be ne in accordance with all SAN JOAQUIN CcuN-N Ord' 'nee Code ,Standards,STATE and <br /> FEDERAL la-MS. <br /> /\'� <br /> APPLICANT SIGNATURE:- -k7 DATE: / v <br /> PROPERTY/BUSINESS OWNER C OPERATOR/MANAGER Cl OTHER AUTHORIZED AGzw Cl <br /> It APPLY—w is not Lha ekLr-G Pproof of au tha*2tion to sign is mquirad 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 environmentaVsite assessment information to the SAN JOAQUIN COUNTY PuouC HEALTH SERVICES ENVIRONMENTAL HEALTH DNiSfON as soon <br /> as it is available and at the same time itis provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> Oi <br /> I, - N_I <br /> COMMEMS: RECEIVED <br /> lUlZ9/d3 <br /> SEP <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> Q / ENVIRONMENTAL HFAITH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: E ePtCY�ih DATE' <br /> ASSIGNED TO: / EMPLOYEE#: 5— C DATE: <br /> Date Service Completed (if already completed): SERVICECODEP 1 E: <br /> Fee Amount: $ I Amount Paid '146 Payment Date g/zj/�-j <br /> Received By: <br /> ?aymentType V Invoice"n Check# <br />