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SERVICE REQUEST <br /> t - <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR BILLING PARTY❑ <br /> FACILITY NAME <br /> SITEADDRE S V <br /> UStreet Number D�7�ction SIrW Name Typa Suite 0 <br /> Mailing Adldresls (If Different from Site Address) <br /> CITY STATE zip <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR fBSG PARTY❑ <br /> -� fit./ <br /> BUSINESS NAME PHONE# E.T. <br /> 14/ <br /> MAILING <br /> /l/1 <br /> MAILING ADDRESS FAX# <br /> CiTV STA--.-E zip <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business comer,operator or authorized agent of same,acknowledge that all site and/or project specific <br /> PUBLIC HE.LTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this proj�;-A or activity will be tilled t0 me or my business as identified on this form. <br /> I also certify that I have prepare:)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 /> APPUCANT SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLCANr is not the StuwG P wn proof of authorization to sign is required ri tf e <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 environmentaVsite 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: <br /> I -0 0VED <br /> DEC 610 <br /> dUAQUIN GvUNTY <br /> PUBLIC HEALTH SERVICES <br /> NVIRONMENTA,.HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY�� EMPLOYEE#: /T�'yo1 DATE: <br /> ASSIGNED T0: EMPLOYE l��''��'' DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: k ' P 1 E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br />