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i <br /> �( SERVICE REQUEST EH0061SR revised 07/10/98 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> �Db BILLING PARTY <br /> FACILITY NAME 6 l berfi tirotnt h l <br /> t'.�. Gu M <br /> SITEADDRESS <br /> Street Number Direction Street Name Type Suite# <br /> Mailing Address (If Different from Site Address) <br /> x7011 5. u tt'n I&J <br /> CITY t STATE C 6 ZIP <br /> PHONE#1 EXT. PN# LAND USE APPLICATION# <br /> s�� 4�,q ms - q� - t6 <br /> PHONE#2T• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR . 1 V-I(� /Q � of C� BILLING PARTY El <br /> BUSINESS NAME r J �" PHONE# EXT.. <br /> r N'QI ( U- � P�SGh ►I15oC. d X30-3701 <br /> MAILING ADDRESS -bu qD+n f✓1 FAX# <br /> 001) 333 -fr303 <br /> CITY Lod <br /> I' STATE 0 6 ZIP ?/ C; yv <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 cation and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br /> Ordinance Codes, Standards, S d F ERAL laws. k/ <br /> APPLICANT SIGNATURE:f= DATE, /—�� <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY 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, <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: <br /> I S <br /> COMMENTS ❑ SPECIAL CONDRION(S)OF APPROVAL❑ OTHER ❑ <br /> INSPECTOR'S SIGNATUR j CONTRACTOR'S SIGNATURE: DATE: <br /> a LI- <br /> 4 Ld <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED To: - EMPLOYEE#: C DATE: <br /> Date Sery mpleted): -2— O`U SERVICE CODE: 2 P/E: � () <br /> Fee ount: Amount Paid �S� .C)o Payment Date a 7 DO <br /> Payment --- Invoice# Check# Received By:\-/ <br />