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SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />BUSINESS NAME <br />62-121-7OW <br />E i OPERATOR ILLING PARTY <br />i <br />FACIL . <br />SITE ADDRESS <br />STATE ZIP 50 C_. <br />Street Number <br />Ir on <br />Type I Suile 0 <br />Mailing Address (If Different from Site Address) I <br />CrrY STATE ZIP <br />M <br />PHONE #1 EXT, <br />APN # <br />LAND USE APPLICATION # <br />ASSIGNED TO: <br />I EMPLOYEE <br />PHONE #2 EXT • <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUES <br />BILLING PARTY 0 <br />COMMENTS:PANIP <br />BUSINESS NAME <br />E # T. <br />MAILING ADDRESS <br />I '-Oct <br />CITY <br />STATE ZIP 50 C_. <br />BILLING ACKNOWLEDGEMENT: 1, 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 DrAS;CN hourly charges assoGated 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 prepa 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 />o sZr <br />PROPERTY / BUSINESS OWNER OPERATOR 11I ANAGER k OTHER AUTHORIZED AGENT �t <br />kLAPat�vrris the F.wrr proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When ap`pjta#ie!( 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 environmentaYsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DNISION 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:PANIP <br />AN <br />NOVViECEIVED <br />191999 <br />` AN JOAQUIN CUUN m r <br />ENVIRO UC HE � SERVICES <br />HEALTH DIVISION <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY: - �J <br />EMPLOYEEr'1 _1 <br />DATE: <br />ASSIGNED TO: <br />I EMPLOYEE <br />DATE: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: L P f E:.. �( <br />J_ <br />Fee Amount: <br />Amount Paid oZ� <br />Payment Date l (loWl <br />Payment Type Invoice # <br />Check 4 <br />I 0 q5q Received By: 1,6 <br />