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SERVICE REQUEST "' EH0061SR revised 09/04/98 <br /> 'ype of Business or Property FACILITY ID# SERVICE REQUEST <br /> OWNER I OPERATORW' BILLING PART <br /> FACILITY NAME <br /> SITE ADDRESS Va 3 J f Street Number Direction � � Sheet 04 Name Type Suite i <br /> Mailing Address (If Different from Site Address) <br /> CITY �.0. oJl f, $$ �} STC Al .0.7 <br /> ✓.0.7 V t7 <br /> PHONE#1 Err. APN# G 1 245 g LANG USE APPLICATION# FAI Ol� <br /> 6 0 . 11646 1 <br /> I <br /> PHONE#2 BOS DISTRICT LOCATION CODE <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REQUESTOR -r d BILLING PARTY❑ <br /> BUSINESS NAME PHONE# Err. <br /> MAILING ADDRESS -� 351 <br /> G✓ , FAX# <br /> k-ITY <br /> Oc KiQ A <br /> STATE C"I ZIP ��b <br /> BILLING ACKNOWLEDGEMENT: 1, 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 I 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, ST�AT/E]and FER/E�L laws. <br /> APPLICANT SIGNATURE: / ' I a Iey DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑if APPLICANT is not the BILLING PARTY Proof of authorrzation 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 /> -lereby authorize the release of any and all results, geotechnical data and/or environmentallsite assessment information to the SAN JOAQUIN COUNTY <br /> ?UBLIc 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 /> �ARct/'[ �ans M �y tr <br /> COMMENTS ❑ SPECIAL CONDITION(S)OF APPROVAL❑ OTHER []AV11 w��a ❑ <br /> SEP 16 1998 <br /> SAN JOAQUIN COUNTY <br /> a <br /> NViF!CNMENTAL HEALTH DIVISIOr. <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: DATE: <br /> APPROVED BY: EMPLOYEE#: o/O^ DATE: <br /> ASSIGNED TO: EMPLOYEE`: Q DATE- (! 0 <br /> Date Service Completed (if already completed): SERVICE CODE: 5-2-2 P I E: 1 <br /> d o Amount Paid Payment Date q /(, Yyoa <br /> Fee Amount: 6 S 6 <br /> Payment Type Invoice# Check# j(p5 S Received <br />