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/ SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST It <br /> OWNER I OPERATOR <br /> BILUNG PARTY 0 <br /> FAciuTy NAME <br /> SITE ADORES Q ^ <br /> SVMNxne Type Sull�f <br /> Mailing Address (if DiKprent from Site Address) <br /> CITY STATE zip <br /> PHONE#1 APN LUSE APPft <br /> ( l AND LICATION J3,?— � ��1 <br /> PHONE#2 BOS.DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTO <br /> 1 C `? BILLING PARTY <br /> BUSINESS NAME PHONES Ezr. <br /> MAILING ADDRESS FAX# <br /> CITY --y--�' <br /> _7 i"j N STATE rn ZIP -�7 !�" 2 <br /> BILLING ACKNOWLEDGEMENT: 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 DmsioN 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 have prepared Ihis a liption and Ihat the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinanco Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: ` T t ` `' DATE: <br /> PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER 0 OTTIERAUTHORIZEDAGENT 0 <br /> !f Amt wr is not Me Bum PA<rrY proof of authorin don to sign Is roqulrod T i t l o <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,),the owner or operator of the property localed at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and%or environmentallsile assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICEs ENvutoNMENTAL 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 /> 0 � tIA;61,c40•'�'� �x�•T-�-�-�$ I.gG'� "tel t.,-' h tnP <br /> PAYM E T <br /> RECE(V <br /> 0cf92001 <br /> 'eo IV SAN COUNTY <br /> PUBLICOUIN HEQALTH SERVICES <br /> ENVIRONMENTAL HEALTH 01VISI0"d <br /> O <br /> INSPECTOR'S SIGNATURE: ` <br /> .�- CONTRACTOR S SIGNATURE: <br /> APPROVED BY:. f✓V',P—5 L'V EMPLOYEE#: d DATE: <br /> ASSIGNED TO: K o n-'L IEEE <br /> St ti'CL CJ L'� (�l�.� DATE: ��—C1 <br /> Date Service Completed.jif already completed): <br /> SERVICECODE: 10 .P I E: <br /> Fee Amount: 5 Z C <br /> Amount Paid Payment Date <br /> Payment Type Invoice 9' Check tt <br /> received By: <br />