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SERVICE REQUEST <br />CONTRACTUK I StKVIGt Ktwuta I Um <br />v� REQUE570R <br />BUSINESS NAME <br />MAILING ADDRESS <br />CITY <br />PHONE # <br />FAX # <br />STATE ZIP <br />BILLING PARTY ❑ <br />EV. <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 houdy charges associated with this projector activity will be billed to me or my business as identified on this form. <br />1 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 IaWS. <br />may- J <br />APPLICANT SIGNATURE: v'�l/ f / - r� l [`— DATE: //�� <br />PROPERTY /BUSINESS OWNER j OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPUCaur is not the Be u vc Pnrm= Proof of aufhorintlon to sign is squired 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 PueuC HEALTH SERVICES ENVrRONMFIJTALHEAL F+ 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: LA rr✓Sc o�-- <br />COMMENTS: <br />INSPECTOR'S SIGNATURE: <br />APPROVED BY: <br />ASSIGNED TO: <br />Date Service Completed ('If already completed): <br />Fee Amount: .0 <br />Payment Type Invoice 4 <br />CoKwccTOR'S SH <br />Empt.cYEEit qhs <br />EMPLOYEE #: 3 S 4 <br />ll <br />Amount Paid i t01 <br />Check # <br />PAYM E N I <br />RECEIVED <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />DATE: <br />DATE: <br />SERVICECODE: <br />Payment Date <br />P1E:. <br />Received Ely: <br />