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• SERVICE R <br />EQUEST <br />Type of B mess or P�";� <br />�o,S <br />BUNG PARTY ID <br />FACILITY ID # <br />COMMENTS: <br />SERVICE REQUEST # <br />Do J 6 `/ <br />MAILING ADD ESSi6� <br />FAX # / <br />CITY <br />STATE zip <br />OWNER OPIOATOR`V f:� � <br />/v <br />� <br />BILLING PARTY C1FACILITY <br />NAM � f�d <br />SITEADDRESS 09 <br />cq <br />ml. <br />SAN JOAOU,r< COUNTY <br />PUBLIC HEALTH SERVICES <br />/ Strut Number <br />Direction <br />7 / ll tr N <br />INSPECTORS SIGNATURE:JJ <br />Type <br />sutte I <br />Mailing Address (If Different from Site Addres r ^r k 50 77, <br />EMPLOYEE #: �CJ � <br />CITY <br />STATE zip <br />P�HOONP #1 _ <br />Imo" // � / U u W �l� <br />APN # 7LAND <br />USE APPLICATION # <br />PHO E#2 _ T7C) <br />( <br />Eii. BOS:DISTRICT <br />kAJ <br />LocATION CODE: <br />CONTRACTOR I SERVICE REQUESTOR <br />REQUESTOR(/ "0 <br />V� <br />BUNG PARTY ID <br />BUSINESS WE <br />COMMENTS: <br />PHONE# EXT. <br />MAILING ADD ESSi6� <br />FAX # / <br />CITY <br />STATE zip <br />c <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 charges associated with this projector activity will be billed to me or my business as identified on this form. <br />I also certify that I have preps this application and that the work to be performn accordance oAOuiNOUNTY <br />ed will be done idwith all SAN JCOrdinance Codes, Standards, STATE and <br />FEDERAL laws. / ? �-� <br />,APPLICANT SIGNATURE:v DATE: 0" <br />PROPERTY I BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <br />IfAPPt.r wr is not the l3u m Purr proof of authodzntlon to sign is requirod 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 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DNisiw 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:G'�LJ" C% <br />k� <br />COMMENTS: <br />PAYMENT <br />RErEIVED <br />SAN JOAOU,r< COUNTY <br />PUBLIC HEALTH SERVICES <br />FNVIRONMENTAt. HEALTH DIVISION <br />INSPECTORS SIGNATURE:JJ <br />CONTRACTORS SIGNATURE: <br />APPROVED BY:. <br />EMPLOYEE #: �CJ � <br />DATE: <br />ASSIGNED TO: �],� 561 I b� t bO �ttf <br />EMPLOYEE#: <br />DATE: <br />Date Service Completed (If already completed):SERVICECODE: <br />C <br />P! E: <br />Fee Amount: `ZC '� Amount Paid _`7 _ <br />Payment Date 0 <br />Payment Type <br />Invoice #' <br />Check # 5 f rj <br />x ` <br />Received By: <br />M <br />