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l SERVICE REQUEST <br />T e of Bus iartss.or Pro erty <br />1 <br />% 5PaJ r-0 <br />'�-, tY <br />FACILITY ID # <br />SERVICE REQUEST # <br />F'� <br />CONTRACTOR'S SIGNATURE: <br />�'ov 3 �� <br />S� � 29a 33 <br />0 ER f OPERA7OMV L� <br />DATE: � <br />BILLING PARTY Cl <br />l <br />�� ., <br />EMPLOYEE #: �t7 V <br />fJ <br />FACILITY NAM(&, <br />Date Service Completed (if already completed): <br />SR <br />SERVICE CODE: <br />P ! E: 2 30p <br />Fee Amount: 2Cr 7 <br />Amount Paid <br />/DRESS <br />7 u Strett Number <br />eceon <br />Name <br />Typa <br />Svite! <br />Mailing Address (IfDifferent kom Site <br />Addre7 <br />Received By: �'.Y <br />O .. <br />Cm' <br />TATE IP <br />0, <br />P�HHONNEE#1 <br />ExT• <br />APN# <br />LAND USE APPLICATION# <br />PHONE #'L <br />BOS:DISTRICT LOCATION CODE. <br />CONTRACTOR I SERVICE REQUESTOR <br />BILLING PARTYAO <br />BUSINESS NAME •V� /yfA_ ,,,�y „Cy L_ n� �� )t PHON # ,l / �, / J _ ✓J EXT. <br />MAILING ADD S C/�/i 1 (� l` (J/�/ ( (�1 T <br />CITY \ t OIL STATE zip <br />BILLING Af-'KNOWLEDGEMENT: 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 DmSION 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 have prep this appligtion 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 />e f �l-/ ( � ' / Z <br />APPLICANT SIGNATURE: , DATE: [�r <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR I WNAGER ❑ OTHER AUTHORIZED AGENT <br />If Apar wr is not the Aum P proof of authorizatlon to sign Is mquired 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 environmentallsite assessment information to the SRI 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 />1 <br />% 5PaJ r-0 <br />'�-, tY <br />COMMENTS: <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY:, <br />EMPLOYEEM <br />DATE: � <br />1 ' <br />/ V <br />ASSIGNED T0: <br />�� ., <br />EMPLOYEE #: �t7 V <br />fJ <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P ! E: 2 30p <br />Fee Amount: 2Cr 7 <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice 9' <br />Check 4 5 I C�3 <br />Received By: �'.Y <br />