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R <br />� SERVICE REQUEST <br />Type usiness or�r6perty <br />% <br />COMMENTS: <br />FACILITY ID # <br />SERVICE REQU��EST q <br />(Do <br />Y <br />` <br />AL I'tEALTfYP,�tIfSK;� <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY: <br />EM?LOYEE #: ODD <br />OWNER / PERAT�, <br />ASSIGNED TO: S <br />EMPLOYEE #: <br />DATE: <br />t <br />BILLING PARTY El <br />% <br />SERVICE CODE: <br />EP E: <br />Fee Amount:3 • (`JrE? <br />Amount Paid a 3 M—"'" " <br />Payment Date <br />FACILITY NA <br />Invoice # <br />Check # G� 3 <br />Received B !44�3 <br />c' <br />SITE ADDRESS <br />/i �U�t+eet <br />Street Number <br />Direction <br />Gf <br />NamType <br />Su to # <br />Mailing Address (If Differen om Sit=Ades <br />Gj <br />C17Y <br />i <br />7 � <br />STATE RS Z —� <br />PHONE #1 <br />APN # <br />LAND USE APPLICATION # <br />PHON # <br />E.T. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR/ SERVICE REQUESTOR <br />BILLING PARTY <br />BUSINESS NAMe��/ 4�7,1 / 6k i111�J <br />PHt � / <br />I MAILING ADDRESS P) "- r / ® 1" tri i //1. C // /n % — /- -3%! <br />CRY 'T!!17A- T% / U I STATE � 0 PL I <br />BILLING ACKNOWLEDGEMEW: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific <br />PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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 hav reps licabon and ththe work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and <br />FEDERAL laws. <br />APPLICANT SIGNATU : ( l / J t DATE: 11E <br />i� <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR / MANAGER OTHER AUTHORIZED AGENT RWJ <br />If APPLrcanr is not the BILING Paltry. proof of authorization to sign is requi Title <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 environmentallsite 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: <br />Y <br />AL I'tEALTfYP,�tIfSK;� <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY: <br />EM?LOYEE #: ODD <br />DATE: <br />ASSIGNED TO: S <br />EMPLOYEE #: <br />DATE: <br />t <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />EP E: <br />Fee Amount:3 • (`JrE? <br />Amount Paid a 3 M—"'" " <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # G� 3 <br />Received B !44�3 <br />