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SERVICE REQUEST EH0061SR revised 07/10/98 <br /> [[TytpeofBusiness or Property FACILITY ID# SERV CE 5JUEST# <br /> 4 SO <br /> MOP- <br /> OWNER I OPERATOR3� J BILLING PARTY❑ <br /> FACILITY NAME / / J <br /> SITE ADDRESS y1 <br /> Street Number Direcb /TG A r"1 C rt T <br /> Street Name I / Type Suite# <br /> Mailing Address (If Different from Site Address) <br /> CITY � �' �ATEt ZIPC <br /> v , <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR ISERVICE REQUESTOR <br /> REQUESTOR <br /> BILLING PARTY <br /> BUSINESS NAME PHONE# EXT. <br /> Ix- 1 (201711 <br /> MAILING ADDRESS <br /> CITY STAT ZIP r' <br /> > cmc_ t t � <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 that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br /> Ordinance Codes, Standards and F ERAL law. . / c� <br /> APPLICANT SIGNATURE: --.` C ---- DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MAN R ❑ OTHER AUTHORIZED AGENT ❑ <br /> It APPLICANT is not the BILLING PARTY proof of authorization t0 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: v I � (- J <br /> ! <br /> COMMENTS ❑ SPECIAL CONDrrION(S)OF APPROVAL❑ OTHER ❑ <br /> ---- --- DEC 10 1998 <br /> SAN jOAQUIN <br /> PUD C HEALTH SE <br /> RV <br /> 'Uj.NTY <br /> ENVIRONMENTAL HEA, ICES <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: DATE: <br /> APPROVED BY: �' EMPLOYEE#: DATE: " (v <br /> ASSIGNED T0: �� EMPLOYEE#: -21 _ DATE: Z l C <br /> jDate Service Completed (if already completed): SERVICE CODE: r �— PIE: j <br /> Fee Amount: �`(J. (!)�D Amount Paid C - ,l Payment Date � �� f <br /> Zl <br /> Payment Type Invoice# Check# a 73 Received By-' <br />