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SERVICE REQUEST <br /> y e of Busine r rop 1 FACILITY 1D# SERVICE REQUEST# <br /> FA 060 �3 co 9 0 <br /> 0 ER/OPERATO BILLING PARTY 0 <br /> FACILITY NAME J <br /> SfjEQj2ESS I C <br /> StrM Num6v Direction SbM Numov <br /> Type Sufl�l <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE zip <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> c+11) <br /> PHONE#2 Err. BOS;DISTRICT LOCATION CODE . <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOI( aA" <br /> d <br /> BtLLtNG PAR <br /> BUSINESS NAME pH�# EzT, <br /> MAILING ADOR FAX# <br /> / t/ <br /> CITY /I s zip — <br /> BILLING AC OWLL�DG MENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project specific <br /> ts <br /> PUBLIC HEALTH SERvlcENVIR MENTAL HEALTH DMSiON 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 havk,prepa .�s Iicafion and Ih the work to be perforated will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws, v ` <br /> DATE: <br /> APPLICANT SIGNATURE: I <br /> � V <br /> PROPERTY I BUSINESS OWNER 0 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> 11 Apmc wr is not the ftLm P wry proof of authorization to sign Is roqulmd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property kmted at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentaftte assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENvIRONMENTAL HEALTH DtvisioN 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 /> INSPECTOR'S SIGNATU CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. Eh1PL0YEE#: �s DATE: <br /> ASSIGNED TO: <br /> EMPLOYEE 9: ��;5 DATE: <br /> d <br /> Date Service Completed (if already completed): v a�Fi SERVICE CODE: ' PIE: <br /> Fee Amount: 2 \Jt f Amount Paid i / <br /> Payment Date I ,i <br /> Payment Type Invoice# Check# Received By: <br />