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• SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR BILLING PARTY 0 <br /> CLtevv �� <br /> FACILITY NAME <br /> SITE ADDRESS <br /> LCJ � may-. �k-w� •�-� <br /> ©S— Street Numbs Direction Street Name Type Suite a <br /> Mailing Address (If Different from Site Address) <br /> CITY ' I ' STATE Zip <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> (`72r) �l Z —76-b 2 <br /> —7 <br /> — – I I --T- <br /> PHONE#2 EXT. <br /> 5 � (� 7BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTER BILLING PARTY <br /> U) Z (:�7 /�' <br /> 61 <br /> BUSINESS NAME PHONE# EXT. <br /> ING DRESS FAX# <br /> o`F 1`/In1 ©3 a - ' ') i.2— <br /> STATE zip "� S2, <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 DNISION hourly charges associated with this project or activity • be billed tome or my business as identified on this form. <br /> 1 also cerlity that I have prepared this application and that the work to be <br /> pe <br /> vpill be do i accord with all SAN JOAQUIN COUNTY Ordinanco Codes,Standards,STATE andFEDERAL laws. <br /> PPLICANT SIGNATURE: DATE: — — 2 <br /> IYROPERTYIBUSINESS OWNER ❑ OPERATOR/WNAGER ❑ OTHER AUTHORIZED AGENT —Z'— <br /> YAPvr r-wr is rat the UILByG Pnmv proof of authorization to sign is required Title <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 environmentaVsile assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENviRoNMENTAL HEALTH DrvlsioN 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: VL ST <br /> COMMENTS: <br /> tECEIVE 4 <br /> M& MAV 2000 <br /> SANJOk.JLjN <br /> % 'N''�'.ra: ✓� ENVIRONMENTAL HEALTH t <br /> 7-NVfi{ '61r1 � DIVISIOt <br /> �EAL7H'Dtd�:C <br /> INSPECTOR'S SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY:. tt+�. /d �t f s ��� EMPLOYEE#: DATE: <br /> ASSIGNED TO: /' <br /> EMPLOYEE#: DATE: w <br /> Date Service Completed (if already completed): �• <br /> SERVICE CODE: SCP I E: <br /> Fee Amount: 3 Y, Amount Paid Payment Date s/s/OG <br /> Payment Type Invoice#• Check# ` <br /> Received By <br />