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SERVICE REQUEST <br /> Type o(—Pusiness or P p rty rACILITY ID# SERVICE REQUES " <br /> � 7 <br /> OWNER/OPERAT BILLING PARTY ii <br /> FACILITY NAME <br /> SITE ADDRESS t�/�J� <br /> j str"I Humber Dlr.ctlon - Home s Suits/ <br /> Mailing Address (If Different from Site Address) <br />) CTTY STATE �-+,G� ZIP <br /> i <br />' PHONE#1 Er. APN# LAND USE APPLICATION# <br /> i ( <br /> f' PHONE#2 BOS DISTRICT LOCATION CODE <br /> j <br /> 1 <br /> i <br /> CONTRACTOR/SERVICE REOUESTOR <br /> I REQIIF.STOR BILLING PARTY❑ <br /> i <br /> �J4 r—ISTv --e- � �E <br /> BUSINESS NAME <br /> j PHONE# Tar. <br /> MAILING ADDRESS FAX# <br /> CvSc--> ",-,'JC r=jU ('A4611 -4&0d� <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 DIVISION 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 prepared this application and a work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards,STATE and ' <br /> j FEDERAL laws. / <br /> t APPUCANT SIGNATURE' DATE: ;7/GIP <br />�1! <br /> PROPERTY/BUSINESS OWNER ❑ OPErRATOR I MANAGER OTHER AUTHORIZED AGENT ❑ <br /> M APVUcmr is not ghe 8LLm PA8 pmol o!authorization to sign is requhad f i f I 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 Into maton to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OtvISION as soon <br /> as If is available and at the same Ume it is provided to me or my representative. <br /> j! TYPE OF SERVICE REQUESTED: <br /> j COMMENTS: <br /> 1 - <br /> r <br /> PAYMENT <br /> RECENE , <br /> NOV 2 3 1998 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTORS SIGNA E: CONTRACTORS SIGNATURE: -7 <br /> APPROVED BY: EbPLOYEE#: ` DATE: z__3 <br /> 1 <br /> ASSIGNED TO: EMPLOYEE#: DATE: a 3 <br /> Date Service Completed (If already completed): SERVICE CODE: Q`j P I E: <br /> Fee Amount: Amount Paid 3 V C Payment Dale <br /> Payment Type ✓ Invoice# Check# �5tf(,p Received By: <br />