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e <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# Ms -- Z SERVICE REQUEST# <br /> 49 =2 <br /> OWNER I OPERATOR BILLING PARTY❑ <br /> R0hq/c/ .S7calf�l� <br /> FACILITY NAME <br /> SITE ADDRESS N. Ck►M�KF� Pd , N c/etMeh�s (2� <br /> Street Number Direction SVM Nano <br /> Type SuNe/ <br /> Mailing Address (If Different from Site Address) <br /> na 3CITY � <br /> STATE ZIP <br /> PHONE#1T• APN# LAND USE APPLICATION# <br /> 2-1 <br /> PHONE#2T• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BIDING PARTY 0 <br /> J;q <br /> BUSINESS NAME PHONE# Exr. <br /> MAILING ADDRESS FAX# <br /> .5-3.ss s� �Q�. r e���c <br /> CRY STATE ZIP <br /> oc szjs— <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or projectspecific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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: ? DATE: <br /> PROPERTY/BUSINESS OWNER O OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT O <br /> II Apruc wr is not the Bun G Paan proof of authorization to sign Is requlrad Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,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 informabon to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DNISION 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: ��✓1�, So / Sal fa bill/` <br /> COMMENTS: _ <br /> V.* <br /> ;7r7 �I c��p� /I�oYL7�e �ec; ti ,A.%, t <br /> 2— <br /> • CT yO/��h <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: r <br /> APPROVED BY-'� EMPLOYEE#: � DATE: C' <br /> ASSIGNED T0: EMPLOYEE#: ( (� DATE: <br /> Date Service Completed (if already completed): (SERVICE CODE: <br /> 77 O U ' 7_' � c .PIE: <br /> Fee Amount: Amount Paid ,6 <br /> Payment Date <br /> Payment Type Invoice#' Check 9 ; 77 Received By: <br />