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4 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Dv�-0 q 0 <br /> OWNER/OPERATOR BILLING PARTY❑ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Z l ae I Street Number arecton l J street Name Type Suite R <br /> Mailing Address (If Different from Site Address) <br /> e <br /> CITY �p ` STATE C4 ZIP q C Z -7 <br /> PHONE#1 J APN# LAND USE APPLICATION# /J <br /> ( ) <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY <br /> BUSINESS NAME PHONE# 2 / T• <br /> MAILING ADDRESS _ FAX# <br /> Z I bell, �. <br /> CITY STATE ZIP Z V <br /> i <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 DNISION 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 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 /> APPLICANT SIGNATURE: I 4a,� DATE: IO C <br /> PROPERTY/BUSINESS OWNER Cl OPERATOR/WAGER OTHER AUTHORIZED AGENT D <br /> If APPLxc wr is not the BiurNc aarr 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 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 /> COMMENTS: c� <br /> El V ED <br /> pCT2s ImO <br /> low <br /> E <br /> AN JOskQUIN COON.Y <br /> PUBUC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: O& '"I DATE: <br /> Date Service Completed (if alr9ady completed): 0-Z`rf 61 �,� SERVICE CODE: �)!*>' <br /> PIE: �3 <br /> Fee Amount: r� �_ Amount Paid Payment`Date <br /> Payment Type Invoice# Check# Received By: <br />