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w... s <br /> SERVICE REQUEST EH0061SR revised 07/10/98 <br /> Type of Businel§,-or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR. ` /-J/ BILLING PARTY❑ <br /> ,-_L/ <br /> FACILITY NAME <br /> SITE ADDRESS � ) / <br /> 23-S -7 Street Number Direction Street Name Type Suite# <br /> Mailing Address ifferent from Site Address) <br /> CRY /- / `STATE ZIP 9 5 Z <br /> PHONE#1 C( ExT APN# LAND USE APPLICATION# <br /> PHONE#Z / EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> BILLING PARTY <br /> BUSINESS NAME PHONE# EXT. <br /> ,2o LK <br /> MAILING ADDRESS x FAX# <br /> CITY STATE ZIP <br /> Z <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 t0 <br /> me or my business as identified on this form. <br /> I also certify that I have prepared this application and th t the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br /> Ordinance Codes, Standards, STATE and FE RA S. <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER R OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPUCANT 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 �}I L ❑ <br /> PAYMENT <br /> -- FEB 18 1-9-9-9 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEACFH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: DATE: <br /> APPROVED BY: l EMPLOYEE#. ( DATE: <br /> ASSIGNED TO: -{- EMPLOYEE#: V 6 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: j P 1 E: (D <br /> Fee Amount: f� Amount Paid 5 _ Payment Date <br /> Payment Type I Invoice# Check# C) 9-7c-) Received <br />