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. A <br /> - 40 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0 <br /> OWNER/OPERATOR BILLING PARTY <br /> FACILITY NAM <br /> SITE ADDRESS V,"Ir r <br /> Street Number Direction JV Yoe Swt�! <br /> Mailing Address (If Different from Site Address, <br /> E ZIP <br /> CrrY ,C .�Jll/1 <br /> PHONE#1 Ex APN# LAND USE APPLICATION# <br /> ( <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQU BILLING PARTY C <br /> BUSINE G �l HONE# EAT <br /> - - - e�S --- -- - 3S <br /> MAII-11 ADDRF S # U7 C— <br /> Cm, � STATE ZIP <br /> Q T� <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authortzed agent of same, acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly urges assocated with this project or aCJvity 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 CCUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: !/ V / C Tt DATE: <br /> PROPERTY/BUSINESS OWNER Cl OPER ATOR I MANAGER OTHER AUTHORIZED AGENT ❑ <br /> NAaotr is not the Fear proof of outhorizadon to sign is required T <br /> ,Curi t l 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 environmentallsite 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: '-Rot I <br /> ;^ \ <br /> COMMENTS: ENT <br /> 'SEP 14 JS9 <br /> PIJBU H SERVICES <br /> ENVIRONMLNTAL HEALTH DiVISION <br /> INSPECTOR'S SIGNATUR CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE W DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Z3O P 1 E: <br /> Fee Amount: AtK ^1 Amount Paid / � ) I Payment Date rill +-L <br /> Payment Type Invoice# Check-g , I Ci Received By: <br /> i3 U <br />