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SERVICE REQUEST <br /> EH0061SR revised 07/10/98 <br /> Type of Business or Property [FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR q- <br /> BILLING PARTY❑ <br /> FACILITY NAME C <br /> SITE ADDRESS <br /> 90 IUB .�at>,trS � /A a t s�'`Ir e Q <br /> Street Number Dir on Street Name Type Suite X <br /> Mailing Address (If Different from Site Address) <br /> 2- <br /> CITYSTATE ZIP <br /> e c a- `� S~ 3.3.� <br /> PHONE#1EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR 7C Q <br /> REQUESTOR <br /> - D BILLING PARTY <br /> BUSINESS NAME PHONE# ExT. <br /> Jz <br /> MAILING ADDRESS ` FAX# <br /> 31�5� W I w a �t <br /> CITY S �m C ! l U STATE ZIP �S (� S•--- <br /> BILLING ACKNOWLEDGEMENT: 1, 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 to <br /> me or my business as identified on this form. <br /> I also certify that I have prepared this ap lication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br /> Ordinance Codes, Standards,ST and EOERAL haws. <br /> APPLICANT SIGNATURE: // DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/ V/1 R ❑ OTHER AUTHORIZED AGENT �r i.P C' N Vk� <br /> If APPLICANT IS IIO a BILLING PARTY proof of BUthor/28f/00 f0 S!9!1 IS I¢QUIr¢d �- Title <br /> AUTHORIZATION TOAELEASE 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 /> TYPE OF SERVICE REQUESTED: <br /> ._ Zug` <br /> COMMENTS ❑ SPECIAL CONDITION(S)OF APPROVAL❑ OTHER ❑ <br /> i <br /> �>✓ p✓ DEC 16 1998 <br /> ---------- --- <br /> SANJOAQUIN <br /> PUBLIC HEALTHSERV, <br /> ---- -- ---- ENVIRONMENT SERVICES <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: SInDATE: <br /> i <br /> APPROVED BY: EMPLOYEE#: vvV ( DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Com e • (if a ead completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid fam --� Payment Date I1-1,1 <br /> Payment Type ✓ Invoice Check# Received By: C4,9�� <br />