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SERVICE REQUEST • <br /> yp of Bu ' es or roperty !FACILITY ID# SERVICE REQUEST# <br /> LI <br /> NE IOPE TOR <br /> BILLING PARTY❑ <br /> FAC N <br /> SITE ADD SS <br /> t�Street Number D n - K- <br /> Mailing Ad (If Diff rent from Site AddresJ e' Tie suftea <br /> L J5 <br /> CrrY <br /> TATE Zip <br /> PHONE#1 Ems• APN# <br /> LAND USE APPLICATION# <br /> PHONE#2 _ L Exc BOS DISTRICT <br /> LOCATION CODE` <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUE OR ` <br /> /i BILLING PARTY <br /> BUSINESS ::ZV <br /> PHONE# T, <br /> MAIZ A3 <br /> LING ADDRESS FAX# <br /> I <br /> /-1' <br /> CITY <br /> STATE Zip <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 ONMENTAL 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 hav pre red this application and that the work to be performed will be done in accordance with all SAN JoAOUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATU DATE:a"- <br /> , <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT (��ffAPPLCWisnot theByiwpumproofofauthoraatfnnfosignfsrequiredAUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner oro rator of the roifle <br /> any and all results,geotechnical data and/or environmentallsite assessment information to the SAN JOAQUIN COUNTYPUBBLItCC HEALTH SERVICES ENVIIRONMEN ALHaEALTH DIVISION las 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 /> PACE vED <br /> RE <br /> J�� 1 <br /> 2 2040 <br /> ENSwOauVk <br /> pN\-Z <br /> EcSO�N <br /> VIRNMEN <br /> INSPECTOR'S c0E1VsI <br /> SION <br /> SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: <br /> EkPLOYEE#: If r DATE: 7 <br /> ASSIGNED TO: EN!PLOYEE# �f DATE: C <br /> :Date Service Completed (if already completed): (r <br /> SERVICE <br /> Fee Amount: Amount Paid <br /> Payment Date <br /> Payment Type :r Invoice# Check# Il4 t <br /> 3 Received By: <br /> J <br />