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SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST vf cto-3 <br />BUSINESS NAME <br />PHON # FXT. <br />F Z <br />C-� - I, <br />MAILING ADDRESS <br />OWNER / OPERATOR <br />BILLING ARTY <br />LR Lo cl <br />FACILITY NAME <br />STATEE N ZIP 2 <br />�\ <br />SITE ADDRESS <br />V6Q Street Number <br />Direction <br />U^Z N <br />Type <br />Suite <br />Mailing Address (If Different from Site Address) <br />CITY <br />STATE ZIP <br />r <br />PHONE #1 Fr• <br />( <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 FST• <br />HOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />BILLING PARTY ❑ <br />BUSINESS NAME <br />PHON # FXT. <br />MAILING ADDRESS <br />FAX # <br />C v <br />STATEE N ZIP 2 <br />BILLING ACKNOWLEDGEMENT: 1, 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 this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE a <br />FEDERAL laws. <br />APPUCANT SIGNATURE: 4 G I " DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR! MANAGER ❑ OTHER AUTHORIZED AGENT C3 <br />BAP.gr.wr is not the 6wnc Paan proof of authorization to sign is rsquimd 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/Site 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: P <br />COMMENTS: <br />INSPECTOR'S SIGNATURE: <br />APPROVED BY: I "( <br />s v—� <br />ASSIGNED TO: 1C_ <br />Date Service Completed (if already completed): <br />Fee Amount: 0_ 0 <br />Payment Type Invoice # <br />EMPLOYEE #: <br />EMPLOYEE #: <br />Amount Paid a 314 0 <br />Check # <br />PAYMENT <br />F—CEWD <br />APR 2 6 IM <br />8hiv JUP,QUIN (;C)u ITy <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />SIGNATURE: <br />DATE: <br />DATE: <br />SERVICE CODE: l `I <br />Payment Date <br />3 <br />PIE: -2 0 <br />�Z 9% <br />Received By: 14 =lv <br />