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0 SERVICE REQUEST i Type of Business or Property FACILITY ID # • ..: SERVICE REQUEST # CITY STATE zip a Q NER / OPERATOR tr.yil BILLING PARTY VVI 91Z9 FACI AME �ry pij ENVIgpN ti/ CC)tJtv. ENT I- SERV J" SITE ADDRESS CONTRACTOR'S SIGNATURE: CEo EAlTyOIV APPROVED BY: A _ � EMPLOYEE '#: CroC-) Street Num bv ASSIGNED TO: Street swt. S Mailing Address (If Different from Site Address) SERVICE CODE: PIE Fee Amount: a ` 0J C� \� -T Payment Date r ► Ii9/� T� ZIP PH N #1T• Q125 APN # LAND USE APPLICATION # PHONE #Z EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project spedfic PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly c�,argeS assocated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and r. FEDERAL laws. APPLICANT SIGNATURE: DATE: PROPERTY /BUSINESS OWNER OPERATOR / NAGER OTHER AUTHORIZED AGENT ❑ H is not Ute PAR ry proof of authorization to sign is r9quirsd Title AUTHORIZATION TO RELEASE INFORMATION: When app i e owner or operator of the property located at the above site address, hereby authorize the release of any and all --suits, geotechnicaf data and/or environmental site assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DNISION as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: • ..: CITY STATE zip BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project spedfic PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly c�,argeS assocated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and r. FEDERAL laws. APPLICANT SIGNATURE: DATE: PROPERTY /BUSINESS OWNER OPERATOR / NAGER OTHER AUTHORIZED AGENT ❑ H is not Ute PAR ry proof of authorization to sign is r9quirsd Title AUTHORIZATION TO RELEASE INFORMATION: When app i e owner or operator of the property located at the above site address, hereby authorize the release of any and all --suits, geotechnicaf data and/or environmental site assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DNISION as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: a tr.yil VVI 91Z9 pij ENVIgpN ti/ CC)tJtv. ENT I- SERV J" INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: CEo EAlTyOIV APPROVED BY: A _ � EMPLOYEE '#: CroC-) DATE: ASSIGNED TO: EMPLOYEE #: DATE: Pt Date Service Completed (if already completed): SERVICE CODE: PIE Fee Amount: a ` 0J Amount Paid �,gLfIgo Payment Date r ► Ii9/� Payment Type Invoice # Check # ' o "I S Received By: .