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SERVICE REQUEST EH0061SR revised 07/10/98 <br /> FTe of Busine or Pr perty FACILITY ID SERVICE REQUEST# <br /> OWNER i OPERATOR �J_ BILLING PARTY❑ <br /> FACILITY NAME �'r <br /> i <br /> SITE ADD ESS <br /> / rP �7 StreetNumber erection Street Name Type Suite# <br /> Mailing Address (If Different,lom Site Address) <br /> CITY STATE ' <br /> E'� �` //" <br /> ZIP <br /> PHONE#1 APN# D USE APPLICATION# / <br /> _ � %� � - <br /> PHONE#2 EXT 76-S <br /> DISTRICT LOCATION CODE <br /> 1 n CONTRACTOR <br /> P (SER/VICE REQUESTOR <br /> REQUESTOR <br /> BILLING PARTY❑ <br /> BUSINESS NAME PHONE#. T• <br /> MAILING ADDRESS / 3C-3 ��`, FAX# <br /> CITY L" Zy ! z` � STATE / �, ZIP J �y <br /> Ll C l <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site <br /> and/or project Specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly Charges associated with this project or activity will be billed to <br /> me or my business as identified on this form. <br /> I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br /> Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfAPPUCANT is not the BILLING PARTY 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, <br /> hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS ❑ SPECIAL CONDITION(S)OF APPROVAL❑ OTHER ❑ <br /> ?� y4�� <br /> S' <br /> �4 <br /> `'90 ev��c 99 <br /> tiEvsF,�.�;i <br /> ---- ----- ---- ---- _ . <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: ��L;r DATE: <br /> APPROVED BY: � EMPLOYEE#: �� DATE: <br /> ASSIGNED TO: �j�j EMPLOYEE#: / DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 5 , P 1 E. <br /> Fee Amount: ~0C Amount Paid 3Gt D Payment Date <br /> Payment Type Invoice# Check# Received By: L"�) <br />