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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> OWNER/OPERATOR BILLING PARTY <br /> FACILITY NAME y� <br /> SITE ADDRESS <br /> /�L�' S o�--"�✓��Y'eer NumOr I Direction I Strec Name I Tyo, <br /> j Mailing Address (If Different from Site Address) <br /> or ' <br /> CITY /�� STATE ZIP S I <br /> PHONE#1 ETT. APN# LAND USE APPLICATION# <br /> L76X ,57--os-21 1 "� <br /> PHONE#2 ErT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY <br /> BUSINESS NAME PHONE# FXT <br /> MAILING ADDRESS FAX# j <br /> 0 <br /> Crrr a / STATE LZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authortzed agent of same, =_dcnowiedge that all site and!or project spF:ci;ic <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly urges assocated 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 .nodes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: � DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR!MANAGER ❑ OTHER AUTHORIZED AGENT X <br /> tf APa„r wr is not the 6uitc PAR 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.hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentaUsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same time it is provided to me or my euresentative. <br /> 1 TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> PAYMENT _ <br /> MAR - 1 1999 <br /> SAN JOAOUIN COLIN7Y <br /> PUBUC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: - CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: // �j/�7 EMPLOYEE#: ���/ DATE: / <br /> ASSIGNED TO: / /1/rj EMPLOYEE#: DATE: "7 <br /> Date Service Completed (if already completed): SERVICE CGDE: �� S� P 1 E: <br /> Fee Amount: �� Amount Paid Payment Date <br /> Payment Type ✓ Invoice# I Check 9 3'aq; Received Bv: <br />