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SERVICE REQUEST <br /> I Type of Business or Property FACILITY ID# <br /> SERVICE REQUEST`�j, <br /> OWNER OPERATOR v 7� <br /> BILLING PARTY❑ <br /> FACILITY NAME <br /> SITE ADDRESS��O(DSa.n Numbs Dv-e,fl1111!1: <br /> Mailing Address (If Different from Site Address) T�� som.r <br /> CITY w/ STATE <br /> ZIP <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> ( <br /> PHONE#2 • <br /> BOS DIsTwCT <br /> LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR <br /> Li,q �,.� f-f E�✓�f 2So !`� 1f11G 'c ( �` �5�3%� BILLING PARTY❑ <br /> BUSINESS NAME PHONE; <br /> MAILING ADDRESS <br /> FAX# <br /> CITY �2ESn7v �`�Y –/706- <br /> STATE � IJP 13 72-6 <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 DIVISION hourly charges associated with this projector 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 <br /> SIGNATURE:( �'✓ - /`f't� – �_� Od <br /> DATE: <br /> PROPERTY IBUSINESS OVMER ❑ OPERATOR/MAMGER ❑ OTHER AUTHORIZED AGENT se-av'-,-f <br /> IrAvrtx wr is not rhe QUM P—Agrr Awf of authorization to sign is squired Till o <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 environmentatisite assessment information to the SAJI JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENviRoNmENTAL HEALTH DVIsioN as socn <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: T— <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVED <br /> JUL 2 4 2000 <br /> SAN JO'1QUIN COUNT" <br /> PUBLIC H ALT"SERVICES <br /> DIVISION <br /> ENVIRONMENTAL HEALTH <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. EMPLOYEE#: <br /> DATE: <br /> ASSIGNED•TO: <br /> EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): <br /> SERVICE CooE: iP I E: <br /> Fel Amount: dU Amount Paid t,: L' <br /> Payment Date <br /> Payment Type Invoice h' Check aX <br /> Received By: <br /> �V � <br />