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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR BILLING PARTY❑ <br /> FACILITY NAME <br /> SITEADDRESSvx <br /> / Street Number 61redon Strut Name <br /> TYM SuNe t <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE r t LP <br /> ( �1 <br /> PHONE#1 ExT• APN# LAND USE APPUCATION# <br /> .PHONE#2 UT. BCS DIsma ION CODE: <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> BILLING PARTY <br /> BUSINE,SS�N1AME PHONE# Ext. <br /> W e, \ @v1 7 zo 4'7— 3)� <br /> MAIUN rADORES FAX# <br /> CITY J _ _(,, i CSTATE ZP ':�,5- <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business er,operator or authorized agent of same,acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charg ass ated with this project or activitywill be billed tome or my business as identified on this form. <br /> I also certify that I have prepared is appli tion and that the rk to ed ed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: —Z— <br /> PROPERTY I <br /> Z—PROPERTY/BUSINESS OWNER p OPERATOR/MANAGER Cl OTHER AUTHORIZED AGENT &V-\ <br /> I[Aparamris not the B4LNC PAmr proof of authoruatfon to sign is requirvd 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 environmental/sile assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL 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: V�/ —T:Z <br /> COMMENTS: (� <br /> PAYMEN <br /> RECEAVED <br /> INAR 152Q� . <br /> INSPECTORS SIGNATURE: SAN JUAQUt 'S SIGNATURE: <br /> APPROVED BY:.' ENVIRO L:MAtItATH DATE: _ <br /> ASSIGNED TO: EMPLOYEE#: <br /> DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P!E: <br /> Fee Amount: <br /> ��j f, Amount Paid a D D Payment Date <br /> Payment Type Invoice# Check SI L{ Received By: <br />