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SERVICE REQUEST <br />Type l6f IBUsiness or Pr n . <br />BUSINESS N,711 /�p, <br />FACILITY ID # <br />f <br />SERVICE REQUEST <br />NA r <br />FAX <br />;&r s� •— C (l c hi <br />C STATE 7 <br />MAD 2 6 2081 <br />OWNER PERATOR %� <br />BILLING PARTY 0 <br />FACILITY NAME <br />PUBLIC HEALTH SERVICES <br />"NVIRONNIFNTAL HEAITH DIVISION <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />SITE ADDRESS_ <br />r/ <br />J � <br />Imo, <br />DATE: n ut <br />ASSIGNED T0: <br />Street Numbw <br />Gr <br />Okection <br />� J ` <br />StrMt Name <br />TYpq <br />Sults C <br />Mailing Address (If Different from Site Address) <br />4 <br />a'L2�2 f-1 <br />Payment Date <br />CITY <br />Invoice #' <br />STATE zip <br />PHONE #1 <br />APN # <br />LAND USE APPLICATION # <br />Wo - �SrzU - �L <br />PHONE #2BOS:DtsTRiC7 <br />�-LJ�� - jnC� <br />7 <br />�/%% <br />LOCATION CODE: <br />j CONTRACTOR I SERVICE REQUESTOR <br />REQUEST gLLING ppb <br />BUSINESS N,711 /�p, <br />PHONE#/�• <br />f <br />COMMENTS: <br />MAILING ADdRESS <br />FAX <br />;&r s� •— C (l c hi <br />C STATE 7 <br />M <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 />PUBuc HEALTH SERVICES ENVIRONMENTAL HEALTH DrASION hourly charges associated with this projector activity will be billed tome or my business as identified on this form. <br />I also certify that I have prep )hit application and that the work to be performed will be done in accordance with all SAN JOAMI C TY Ordinance Codes, Standards, STATE and <br />FEDERAL laws. 1 W- <br />j�-�� I <br />APPLICANT SIGNATURE: !/ -e-e;�� DATE: /� X-) / <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br />ltAaaur wr is not the BGm Paan proof of authorization to sign is Mulrod Title <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 DIv1sioN 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 <br />RECEIVEF, <br />MAD 2 6 2081 <br />SAN JOAOUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />"NVIRONNIFNTAL HEAITH DIVISION <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY:. <br />�Wl r1Jvv `C <br />EMPLOY EE#: <br />DATE: n ut <br />ASSIGNED T0: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICECODE: � <br />P f E: <br />Fee Amount:2 0, <br />Amount Paid Ci`( <br />Payment Date <br />Payment Type <br />Invoice #' <br />Check # ` <br />Received By: ` <br />