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� r <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR BILLING PARTY <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Q 00 Street et� 1fedaS Na <br /> Type Suite tt <br /> Mailing Address (If Different from Site Address) <br /> `a 6Yl <br /> CITY ^1,^ n V1 STATE ZIP 2 <br /> y 1f tt/� lX/\ �2 O <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> Aoy) ,Z39--3170 S7 / q(q — L <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR �ssBIWNG PARTY❑ <br /> o� . �� <br /> BUSINESS NAME PHONE# Exr. <br /> MAILING ADDRESS FAX# <br /> 3 5 3 g"3n3 <br /> CITY r ,1 i1 STATE C,4, zip C�G-*7,14 r ) <br /> BILLING ACKNOWLEDGEMENT: II,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 oractivity 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 Codes,Standards,STATE and <br /> FEDERAL laws. <br /> AFPLICANT SIGNATURE: / • DATE: <br /> r <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPucw+r is not the BiLoNG Paary 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 environmentaVsite 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 /> f <br /> COMMENTS: / <br /> RECEIVEn- <br /> DEC 211 �� <br /> CAN JOAQLAN CVUN',Y <br /> 211E W HEAtTfR SERVICES <br /> r=M/IRONI•.RFTIT,,I HFAITH DIVISi(j, <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> j APPROVED BY: `�MJC EMPLOYEE#: tt3c� 1 DATE: r�G <br /> ASSIGNED TO: T. <br /> CZ S�• EMPLOYEE#: DATE: <br /> Date <br /> -- Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: ��t� Amount Paid /�- c ! _ <br /> i sC� - t, �- c 0 Paym nt Date 1. 44; 7 <br /> Payment Type Invoice# Check# Received By:�,;,,'� <br />