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SERVICE REQUEST EH0061SR revised 07/10/98 <br />Type r f Business or Prope / <br />i pm&_0 <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNER/ OPERATOR <br />BILLING PARTY ❑ <br />j FACILITY NAM - <br />MAILING'A'DQRESS0azz/Ax <br />SITE ADD S 1,_3b1 <br />Street Number <br />Direction <br />% Name <br />` STATE ZIP <br />Type <br />Suite# <br />Mailing Address (If Different from Site Address) <br />! <br />CITY <br />STATE ZIP <br />PHON #1 EXT. <br />J3'1 -(W-3 <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />I. <br />BOS DISTRICT <br />APPROVED BY: <br />LOCATION CODE <br />CONTRACTOR f SERVICE REQUESTOR <br />REQUESTOR <br />BILLING PARTY <br />COMMENTS ❑ <br />BUSINESS M <br />❑ <br />PHONE# EXT. <br />MAILING'A'DQRESS0azz/Ax <br />��Y 4 <br />FAX# <br />!! <br />Crry / <br />` STATE ZIP <br />SEP 2 1 <br />BILLING A NOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site <br />and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly Charges associated with this project Or activity will be billed t0 <br />me or my business as identified on this f <br />I also certify that I have prepared thi application and that zio-11) <br />to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br />Ordinance Codes, Standards, STATE nd�EDERAL lawsrAPPLICANT SIGNATURE: DATE: <br />PROPERTY /BUSINESS OWNER ❑ OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT <br />1 -Zi <br />If APPLICANT IS not the BILLING PARTY proof of authorization t0 sign is requh' Titre <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, <br />hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br />f TYPE OF SERVICE REQUESTED: <br />J-L- <br />COMMENTS ❑ <br />SPECIAL CONDITIONS) OF APPROVAL ❑ OTHER <br />❑ <br />L <br />-- <br />SEP 2 1 <br />------ <br />— <br />.A14 CAIaU N UOUNiN <br />PUBLIC HEALI'H SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />INSPECTOR'SNGNATUFIE: <br />G.-� Itvw <br />CONTRACTOR'S SIGNATURE: <br />--— <br />DATE: <br />APPROVED BY: <br />1 n -' ,� <br />rJyV �U✓ "� - EMPLOYEE #: <br />DATE: GI <br />I <br />ASSIGNED TO: <br />,�`. <br />CLi MPLJY8 <br />vvvvvv <br />0 <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: q P 1 E: 30 <br />9 <br />Fee Amount: 1 <br />Amount Paid <br />Payment Date i a is I <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />