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SERVICE REQUEST V { �� <br /> Type f Busin s gr Property /I FACILITY IID# SERVICE REQUEST# <br /> Wlc/1� <br /> OWN I OPERAT91IR BILLING PARTY ; <br /> Z&�n ru) gy&X* <br /> i <br /> i <br /> I FACILITY NAME <br /> SITE ADDRESS o13 ee j, I� /J/y /� <br /> Street Number Direction "' ',r '/ Street Name Type _ Suite# <br /> Mailing Address (If Different fro Site Address) — � <br /> I I <br /> CITY • SAT zip <br /> QZ 44Z <br /> PHONE#1T• APN# LAND USE APPLICATION <br /> c�lC ,2 31 �. <br /> rPHON''#2 EXT- BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTO ,^ BILLING PARTY. <br /> BUSINESS NAME PHONE# <br /> MAILING ADDRESS FAX# / <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 that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL!aws. p Q <br /> APPLICANT SIGNATURE: DATE: O U <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> if APoL cANr is not the BILLING PAR ry proof of authorization to sign is required <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 environmental/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 /> (",J �. <br /> COMMENTS: <br /> PAYMENTI <br /> AUG 2 41998 <br /> SAN JOAQUIN COUNTY <br /> PUE'LiC HEALTH <br /> ENVIRONMENTAL HEALTH D V SION <br /> ERVICES <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: p s' �L Cum n.cE#: C i n4T=: <br /> ASSIGNED TO: v� EMPLOYEE#: C DATE: <br /> 1 r � <br /> Date Service Completed (if already completed): SERVICE CODE: C PIE: <br /> Fee Amount: Amount Paid i Payment Date cf� g <br /> Payment Type Invoice# Ch k# I 1 G�Received By: <br /> LZI <br />