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0 SERVICE REQUEST • <br />Type of Business or Property <br />24L,/Z - � <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNER f OPERATOR <br />BILU G PARTY <br />FACILITY NAME <br />C <br />PHONE#�/� /J p UT. <br />�S1ITEAD(DRRESS <br />/7 � ( StreetNumbr <br />Np _T <br />D&Kdon <br />FAx # <br />' <br />W f r-5 �� W � <br />StwHMO <br />Type <br />SUR*! <br />Mailing Address (If Diff e t from Site Address) <br />CrrY <br />STATE zip <br />cA,z�sr" <br />PHONE #1 ExT• <br />( <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />7OS;DIS <br />TRICT LOCATION CODE". <br />CONTRACTOR/ SERVICE REQUESTOR <br />REQUESTOR <br />BILLING PARTY ❑ <br />/ <br />COMMENTS:RECEIVED <br />BUSINESS NAME � <br />ECE I E f <br />DECEIV ED <br />V <br />PHONE#�/� /J p UT. <br />ING ADDss <br />FAx # <br />CITY �—�O <br />S E zip <br />BILLING ACKNOWLEDGEMENT: 1, undersigned property or business owner, operator or authorized agent of same, acknowledge that an site andlor project spec fie <br />PUBLIC HEALTH SERVICES I WRONMFNi LTH DmstoN 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 Ie pa I ap I work to be performed will be done in accordance with an SAN JOAQUIN COUNTY Ordinanco Codes, Standards, STATE and <br />FEDERAL laws. <br />APPLICANT SIGNATURE: DATE: <br />PROPERTY/BUSINESS OWNER O OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />lfAam.c wr is rat Uv 1321 rrc Purry proof of authorinUon to sign Is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property k>cated at the above site address, hereby authorize the release of <br />any and all results, geotechnical data and/or environmentaftle assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRoNMCNTAL 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 />�C I L <br />/ <br />COMMENTS:RECEIVED <br />ECE I E f <br />DECEIV ED <br />V <br />CHAP 2 <br />SAN JUAUU;N l:Uvly i Y <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />INSPECTORS SIGNA <br />CONTRACTORS SIGNATURE: <br />APPROVED BY:. <br />EMPLOYEE #: <br />DATE: <br />ASSIGNEDTO: G <br />EMPLOYEE #: <br />DATE: i <br />L p <br />Date Service Completed (if already completed): <br />SERVICECODE: l <br />P f E: 2 <br />Fee Amount: I q) <br />Amount Paid 0 <br />Payment Date <br />Payment TypeInvoice <br />#' <br />Check # / i :? <br />Received By: <br />