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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID SERVICE REQUEST# <br /> 60 e0 �C <br /> OWNER/OPERATOR BILLING ARTY <br /> FACILITYE <br /> SITE ADDRESS �l�+f 7 <br /> StreatHumbn Dlr�ctlon 1.-�/�./� TYPE Suit, <br /> Mailing Address (If Different from Site Addressl <br /> CITY \ STAT ZIP <br /> PHONE n1 \1•— EXT• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOIS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUEST BILLING PARTY❑ <br /> BUSINES E ONE# �T <br /> SAO `� i <br /> MAILING DDRESS <br /> CITY 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 ENVIRONMENTAL HEALTH DNISiON hourly d;arges assodated with this project or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this appliestion 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 SIGNATURE: 6 DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/WNAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> N AaoL wr is not fhe ft.tTC PAR proof of authorization to sign is requirvd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.1.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 t0 t,e SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH ONISION 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 /> F:r^ 'T-7 <br /> RF <br /> -P <br /> —ih ,-UN.Y <br /> F`6B; -":ALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE. CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: 2'g�'j DATE: <br /> Date Service Completed (If already completed): ✓ C7 SEWCE CODE: �3O. I P/E: 03 <br /> Fee Amount: ' I Amount Paid I Payment Date <br /> Payment Type Invoice# Check 9 (� Received By: <br />