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SERVICE REQUEST EHOO61SR revised 09/04/98 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR. BILLING PAR <br /> '?�r_�� �u r�/C7Va✓� <br /> FACILITY NAME <br /> SITE ADDRESS ' cy C�.3 ,V4-- 6`13 RAc-K Int 11�.. c 2-,q <br /> Street Number Direction Street Name �� Type Suite <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE zip <br /> PHONE#1 EXT. APN# LAND USErAyPPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT OCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR /j f BILLING PARTY <br /> BUSINESS NAME I \ PHONE# -I 11 T• <br /> SL's C' <br /> MAILING ADDRESS FAX# <br /> CRY STATE zip 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 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,STATE and FEDERAL laws. <br /> APPLICANT SIGNATURE: DAT`-: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ _ <br /> If APPLICANT is not the BILLING PARTY,Proof of authorization to sign IS required 1 i t l e <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: r n J I , p , � <br /> COMMENTS ❑ SPECIAL CONDITION(S)OF APPROVAL❑ OTHER ❑ <br /> PAYM E NJ <br /> MN <br /> SAN----------------------— <br /> PUBLIC HEALTH 3[:Frvlr,IEg <br /> ENVIRONMENTi-1L NFALTI4 DIVIS5in1, <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SiGNATURE: DATE: <br /> APPROVED BY: EMPLOYEE#: 000 DATE: <br /> ASSIGNED T0: / C' EMPLOYEE#: jl�(1 DATE: <br /> I <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: 2Ci <br /> j Fee Amount: l Amount Paid Payment Date <br /> Payment Type Invoice# Check# Reeeived By: <br />