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SERVICE REQUEST <br /> e of us nes or.Property FACILITY ID# SERVICE REQUEST# <br /> t '1Y � �o- e®©& <br /> Dp96ER <br /> f OPERATORBILLING PARTY❑ <br /> � <br /> FACILITY NAlf <br /> {Cy�ru'r�`�ADD E <br /> � (c 1 fif,d.� it Numb. onALA, SVM N d <br /> mj I Type SuNeR <br /> Mailing Address (If Different from Site Address) ( j <br /> CRY STATE ZIP <br /> AR(') (�A --� <br /> PH0NE#1 � � .� „ _E�• APN# LAND USE APPIJCATION# <br /> PHONE#2 / i , �). BOS;DtSTRICT LOCATION CODE:. <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR ( ` ,`' ' BtLLINGPARTY <br /> R 4-, IttVtf 1 <br /> BUSINESS NAME PHONE# 'XT. <br /> MAILING ADDRESS `. a , FAX# <br /> AA 11UM-) <br /> CITY t STATE Zip �( <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge ttiat all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DmStoN 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 pre"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 laws. \ <br /> t �( <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER O OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ! ) <br /> II AavLc wr is not the&i m Purr%proof of authorization to sign Is requr Td t f e <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 environmentaUsite 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 /> COMMENTS: V <br /> PAYMENT <br /> RECEIVED <br /> A:PR 112602 <br /> SAN JOAOUIN COUP ITY <br /> PUBLIC HEALTH°. r' <br /> ENVIPONNiENTA: <br /> INSPECTORS SIGNATU CONTRACTORS SIGNATURE: <br /> APPROVED BY: EMPLOYEE#: Y/ DATE: / <br /> Z a "Z <br /> ASSIGNED TO: / c�NL EMPLOYEE#: j"j F DATE: <br /> Date Service Completed (if already completed): 7 ®SERVICE CODE: t P!E: — y <br /> Fee Amount: -2—(O Amount Paid Payment Date � '4 P o7 <br /> d <br /> Payment Type Invoice#' Check# Received By: <br /> I <br />