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SERVICE REQUEST <br /> Tygl���f Business or Property FACILITY ID# SERVICE gE/rQUE T# <br /> f- C►Cleat �CA U <br /> OWNER/ OPERATOR <br /> Fee gR ,e)C' IAl/ CHECK If BILLING ADDRESS <br /> FACILITY NAME F f <br /> SITE ADDRESS tt- (O/VCcIJe� <br /> 1 Street Number Direction Street Name Type Suite 9 <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> CITY r po Ai STATE eA ZIP <br /> V <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 7 <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS I <br /> BUSINESS NAME PHONE# Ex' <br /> Qu A i T Con%/-7Z0&. NSP'-reT�o1v ) <br /> HOME Ut MAILING ADDRESS / FAX# <br /> f Z S /V� F/t(Ele-A L b Stilt � C7 ( ) S�Z 7 <br /> CTY STATE ZIP <br /> CJDcST� 7 <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 nd FEDE a S. <br /> APPLICANT'S SIGNATURE: ti DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER THEIR HORIZED: GEN <br /> IfAPPLIC4NT is not the 31LLING PARTY proof of authorization is required 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 envirorunentaUsite 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: u�r��` Su$SGr2FigG� ( l,,fr-A/+'(//✓Arro/ Pip, , <br /> COMMENTS: ';;" <br /> JUL <br /> SAN JOAQUIN CGUNII' <br /> PUBUC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVIS!ON. <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: C i EMPLOYEE C1 / I DATE: Z <br /> ASSIGNED TO: EMPLOYEE#: CI (_ ll r DATE. , <br /> Date Service Completed (if already Completed): SERVICE CODE: Q I P I E: <br /> Fee Amount: s G Amount Paid Payment Date <br /> Payment Type Receipt# Check # Received By: <br /> I I <br /> SRREQrev.doc 7/1/1999 <br />