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r <br /> SERVICE REQUEST <br /> Type of Business or Property �, n FACILITY ID # SERVICE REQUa�ES^ /^ <br /> OWNER/ OPERATOR CHECK If BILLING ADDRESS ISI, <br /> woom I _ <br /> FACILITY NAME VKk(40UJ <br /> SITE ADDRESS Zd Z DO I N ICD AD <br /> i <br /> St[44iNum6er Qlre�tlgn I SIr44LarP.e Tvo4 I sgile 4 <br /> HOME or MAILING ADDRESS (If Different from Site Address <br /> r7g y <br /> o� <br /> CITY STATE ZIP <br /> �H C 4 q W1 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> f�So) ;7 z —gg77 ()(q �� �0 -07 <br /> PHONE#Z EXT. FBOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REOUESTOR CHECK if BILLING ADDRESS❑ <br /> PHONE# EXT. <br /> BUSINESS NAME <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> I111.LING .ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific PU[ILIC III'Auit 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 fortis. <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 STATE and FEDERAL laws. <br /> DATE: <br /> I' Z T ' <br /> A <br /> APPLICNT'S SIGNATURE: /I /C/,oL <br /> PROPERTY/ BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT —�1LqIKAeA <br /> If APPLICtNT is not rhe BILLING PARTY.proof of authorization to sigr/ is required •J Title <br /> AIJ'fIIORIZATION TO RELEASF INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> shove site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY PUBLIC HF-.ALT11 SERVICES ENVIRONMI:NTAI.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— t <br /> COMMENTS: <br /> NOW <br /> 5`�P2 <br /> yN JOAQUIN(,3U;,,y <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED 8Y:^ — --- EtoPLOYEE <br /> ASSIGNED TO: vL � <br /> EMPLOYEE#: ( DATE: �— <br /> /� / SERVICE CODE: 3 l PIE: <br /> Date Service Completed lif already r. ted : L ( ` <br /> Few Amount: I�� Amount Paid �5� Payment Date /a 3 <br /> Recei t # Check # Received By: <br /> Payment Type p — ` <br />