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j' SERVICE REQUEST <br /> 1iType of Business or Property FACILITY ID# SERVICE REQUEST# <br /> &)a'n-) S BILLING PARTY❑ <br /> OWNER/OPERATOR <br /> FAG,6TY NAME <br /> 1-41 <br /> SITE ADOR S I Suit 3 Nye Tl'N <br /> Snot Hunter oireetien <br /> Mailing Address (If Different from Site Address) <br /> STATE ZIP <br /> CITY <br /> PHONE#1 �• APN# LAND USE APPLICATION# <br /> PHONE#Z ar• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> BILLING PARTY <br /> REQUESTOR <br /> PH N # DT' <br /> BUSINESS NAME 3 fl� <br /> VI(-lam <br /> F, # <br /> MluL�lr+ RES In V�► / /A (��3J <br /> LC:rr7]Z= STA ZIP S / <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 /> PUaUC HEALTH SERVICES ENVIRONMENTAL HEALTH DrASION hourly charges associated with this project or activity YAP be billed to me or my business as identified on this form. <br /> I 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 laws. <br /> APPLICANT SIGNATURE: DATE:/ ��' _ <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUT mmoAGENT Tit e <br /> If APPuawr a nit the BLLW Purls Prao/of sudwizadon to slgn is required <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 emnronmentallsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DMSION 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: PAYMEt^' <br /> T <br /> RECEIVED <br /> OCT 14 2003 <br /> PUBLICO HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> I APPROVED BY: EmpLQYwff DATE: /d IF <br /> ASSIGNED TO: 1 EMPLOYEE# 3 DATE: <br /> Date Service Compl ed (if already completed): ✓ SERVICE CODE: P/E:. Z3 <br /> Fee Amount: Amount Paid 6;1� Payment Date `� 3 <br /> Payment Type ✓ Invoice# Check 4 1 1 p 3 Received By: <br />