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SERVICE REQUEST <br /> Type of usiness or <br /> r{y FACILITY ID# SERVICE REQUE <br /> Pro / <br /> BILLING PARTY CJ <br /> OWNER I OPERATOR <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 7P6� Strut Numbr OlracUon Thor Smu <br /> Mailing Address (If iff Iii from Site Address) <br /> CRY STATE ZIP <br /> PHONE#1 APN# LAND USE APPLICATION# / <br /> Exr. BOS DISTRICT LOCATION CO-- <br /> PHONE#2 <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQHFSTORBILLING PARTY El <br /> BUSINESS NAME PII°HE�� y-W <br /> MAILING ADDRESS � � A /� „t/, FAX# <br /> CITY L <br /> STATE /j ZIPlJ---�J <br /> � - , 7 C <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project spedrrc <br /> PUBLIC HEALTH SERVICES EWIRONMENTAL HEALTH OIvisioN 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 /> PROPERTY I BUSINESS OWNER O OPERATOR I MANAGER ❑ 0114ER Aurtiommo AGENT ❑_ <br /> M APPLrmr is nod the @41 G PAR pruor of authorization to sign is rvqubvd 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 environmentaVsile assessment into mation to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENIAL HEALIH OrAS;CN as Soon <br /> as If is available and at the same time It is provided to me or my(representative. <br /> TYPE OF SERVICE REQUESTED: S-6CxU C <br /> \ <br /> COMMENTS: <br /> S,q X999 <br /> r` N(j �`� <br /> //,y p 14"-, y�FgyNry <br /> INSPECTOR'S SIGNATURE: CONTRACTORS SIGNATURE: �TyO FS <br /> APPROVED BY: EMPLOYEE#: �j� DATE: ' <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: I P/E: <br /> Fee Amount: CAAmount Paid Payment Dale a4-;l- N <br /> Payment Type ✓ Invoice# Check# (P�5 Received By: L6 <br />