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SERVICE REQUEST <br /> Type of Business or Property FACILITY IQ�00 SERVICE REQUEST# cr <br /> OWNER I OPERATOR BILLING PARTY❑ <br /> FACILITY NAME <br /> SITE ADDRESS I 1 <br /> v O Strsst Numbv W*ctio n t Strut Naim Suits x <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE C ZIP <br /> PHONE#'I APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 �• BOS DISTRICT LOCATION CODE: <br /> CONTRACTOR I SERVICE REQUESTOR <br /> LR2 BILLING PARTY❑ <br /> PHONE# Exr <br /> FAX# <br /> , STATEZIP: 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 ENV)RONMENTAL HEALTH DIVISION hourly charges associated with Ctis projector activity will be billed to me or my business as identified on this fora. <br /> I also certify that I have prepared th• appl'Iption and that the work to be performed vA be done in accordance with ad SAN JOAQUIN COUNTYOd;7 Codes,Standards,STATE and <br /> FEDERAL laws. <br /> `fAPPLICANT SIGNATURE: DATE: /I d ) <br /> PROPERTY/BUSINESS OWN ❑ OPERATOR/MAMA ❑ OTHERAuTHoRREDAGEur ❑ <br /> NAavr_rwisnot tho8th �r ;Pal ,proofofwthoriziUwrrns19+risr�tltwd rifle <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 environmental/Site assessment information to the SAN JOAQUW COUNTY PUBLIC HEALTH SERVICES ENIVIRONPAENTAL 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 /> PAYVi EN <br /> RF0EIVFc <br /> ztgUU ; q 200 <br /> SAN, <br /> PURL, <br /> _.WIROfI,'oi jgiAt H�A:iHDN <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> l <br /> APPROVED BY: EyPLOY�}2: Cc�r� 1 BATE: <br /> ASSIGNEDTO: EMPLOYEE#: DATE: <br /> Date Service Completed (if alreadympl ): SERvlcECoDE: P/E- <br /> Fee Amount � Amount Paid Payment Date 11/2s, <br /> Payment Type ,/ Invoice# Check# , Received By: <br />