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SERVICE REQUEST .• '► <br /> 11 Type f Business or Property FACILITY ID SERVICE REQUEST <br /> �C IZ Lt L V- /Z a L I Q G-- <br /> OWNER/ OPERATOR <br /> CHECK If BILLING ADDRESS <br /> -JD qAJ <br /> FACILITY NAME <br /> SITE ADDRESSL FIV�1 f� <br /> 1 -7300 Street Number Direction f' Street Name Type Suite x <br /> HOME or IL NG ADDRESS (If Different from Site Address) <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APINI# LAND USE APPLICATION# <br /> ( ) X6 - C) �S - -O <br /> 19 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> 1 ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR %� <br /> L/elv CHECK if BILLING ADDRESS <br /> BUSINESS NAME �v PHONE# EXT. <br /> T C1101 /V 2qX27_ P v <br /> HOME or MAILING ADDRESS FAX# <br /> S N- Z d E-2 t-- ( ) <br /> CITY 1)F S .� STATE �� ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges <br /> associated 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 <br /> COUNTY Ordinance Codes,Standards, STA and FE]D laws�A, . <br /> APPLICANT'S SIGNATURE: DATE: 7-Z 3 9� <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER OTHERAUTHORIZ GENT <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is equtred Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and <br /> at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> �5UA Q.e- r�s a� `.e Qw-nQ. <br /> UU <br /> INSPECTOR'S SIGNATURE: �06CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EMPLOYEE #: / DATE: <br /> ASSIGNED TO: Gi�DQ- EMPLOYEE#: I DATE: <br /> Date Service Completed (if already completed): - ?�0_ SERVICE CODE: �j7� P I E• <br /> Fee Amounto/5-9a Amount Paid Payment Date <br /> Payment Type Receipt# Check # C� /� Received By:l' <br /> S RREQrcv.doc 7/111999 <br />