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SERVICE REQUEST <br /> Type of Business or Property <br /> FACILrFY ID# SERVICE REQUEST# <br /> BILLING PARTY❑ <br /> OWNER I OPERATOR <br /> 1SA L,45, pNo, c ffF+ A t-A ti <br /> FACILITY NAME G S <br /> SITE ADDRESS (-'LI 1 c Y l��(ter' <br /> /n� StrM Nyrn Type Suits <br /> 7? 3 <br /> V 0 sv..c Number Direction <br /> Mailing Address (If Different from Site Address) <br /> CITY <br /> STATE Zip C 7 L Z <br /> T• � f} /_. <br /> PHONE#1 �• APN# LAND USE APPLICATION# <br /> SOS DISTRICT I LOCATION CODE <br /> FPHONE#n2 aT• I <br /> CONTRACTOR/SERVICE REQUESTOR <br /> BILLING PARTY❑ <br /> REQUESTOR <br /> euv rvl <br /> Pt) / (v S,0 EXT. <br /> AM <br /> BUSINESS NE � p <br /> /! t 0 f <br /> FAX# <br /> MAILING ADDRESSD o 114�f� SU e`� 1�.� �g y 6' Q� C <br /> CITY SA(-("/7 4N-r?) STATE �_ LP l SY 3 <br /> BILLING ACKNOWLEDGEMENT: I, the undersgned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project spedfc <br /> PUBLIC HEALTH SERVICES ENVIRCNMENTAL HEALTH DNISIGN hourly charges associated with this project or ac5v4 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 /> DATE: <br /> APPUCANT SIGNATURE: <br /> PROPERTY I BUSINESS OWNER Cl OPERATOR/MANAGER OTHER AUTHORED AGENT ❑ Title <br /> If APPLC.wr is not the Bg�c � Ut <br /> pf of auo=dcn to sign is mquimd <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 andlor environmentailsite assessment information to the SAN JOAQUIN COUNTY PUBuC HEALTH SERVICES E•MRONMENTAL HEALTH OMSION 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 /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EIIPLCYEE# DATE: <br /> ASSIGNED T0: <br /> EMPLOYEE#: DATE: <br /> SERVICE CGDE: P/E: <br /> Date Service Completed ('d already completed): <br /> Fee Amount Amount Paid Payment Date <br /> Payment Type <br /> Invoice# Check# Received By: <br />