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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST / <br /> OWNER/OPE TOR BILLING PARTY-ET' <br /> u . � , voww,4 <br /> FACILITY NAME <br /> SIT ADDRE <br /> C' <br /> stra.s Nwnbv Oinction smraat Nam. swi.N <br /> Mailin Address (if Different from Si Address) 6 <br /> E Al <br /> Clrf CST <br /> PHONE#1 N# LAND USE APPLICATION# <br /> HON #2 �• BOS DISTRICT LOCATION AGE <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REQUESTOR /�� j� l,,� CA l / / ILLING PARTY <br /> BUSINESS NAktEI �? <br /> PHONE <br /> Exs <br /> MAILING ADDRESS FAX# <br /> [ — <br /> CITY STATE ZIPg+ �1 <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that ad site andfor project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly Charges associated with this projed or 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 /> APPuCANT SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> 1f AParaGws is not die 8xLwc Pura proof of audwrizadon to sign is r#wmW 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 ardor envitonmental/site 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: / <br /> COMMENTS: tI <br /> PAYMENT <br /> ��I�F1�►l�if' <br /> NOV 3 01998 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISIO <br /> INSPECTOR'S SIGNA E: / CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: C EyPLOY--#: � DATE: <br /> ASSIGNED TO: ✓✓✓ EmpLOYEE#: ��/ DATE: <br /> fJ <br /> Date Service Completed (ff already completed): SERVICE CODE: f P!E:. J <br /> Fee Amount: Amount Paid _ Payment Date QAl, <br /> Payment TypeCAZtjL <br /> Invoice# Check# l S'��� Received By: <br />