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� t <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SIDeNTmZ ZAg 2(C / .61 <br /> OWNER I OPERATOR BILLING PARTY❑ <br /> /01N /Z/,E ' FiZ <br /> FACILITY NAME <br /> SITE ADDRESS E �200/`�S RC)�/p S Street Number Direction Street Name Type Suits# <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE ZIP <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> ( ) /"l5 - y8-1�3 <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY <br /> BUSINESS NAMEPHONE# EXT. <br /> VIA C L E F_l�q ,�cT7' <br /> MAILING ADDRESS FAX# <br /> 0 . Z; ak 37�'� <br /> CITY (�i2 LaL l� STATE zip <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner, operator or authorized agent of same,acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIvisioN hourly charges 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 ap tion and that th rk to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. / e, <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER Cl OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPIX MT is not the SluiNG PAvrr.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 Vie release of <br /> any and all results,geotechnical data and/or environmentallsite 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 representative. <br /> TYPE Of SERVICE REQUESTED: <br /> SO rG Su/ 74 3/L / S7K f2 ,QEV/� <br /> COMMENTS: <br /> PWI" :;,,s .5tt <br /> 4wf eEvEI Y ED <br /> V 1x141 <br /> cm <br /> SAN JOAQUIN COUN l <br /> PUBLIC HEAi_TH SFRViCES <br /> ENVIRONMENTAL HEALTH OIVISIOh <br /> INSPECTORS SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: /,; EMPLOYEE#. ��y DATE: <br /> III&A c7 <br /> ASSIGNED T0: l C%� "1 EMPLOYEE#: C (�/ DATE: / 9 <br /> Date Service Completed (if already completed): [ SERVICE CODE: �— P I E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice#' Check# Received By: <br />