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A • SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 2�� <br /> OWNER/OPERATOR BILLING PARTY 0 <br /> FACILITY NAME <br /> 3e a c a <br /> SITE ADDRESS <br /> Street Number Direction �� O�r ` Type Suits <br /> Mailing Address (If Different from Site Address) <br /> CITY 7o / / e STATE ztp <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> 4,177 - 31// <br /> PHONE#2 T• BOS;DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR / BIWNG PARTY 0 <br /> BUSINESS NAMEff PHONE# EXT. <br /> ,4 ">7t Cc/I C e J n L 20 y> <br /> MAILING ADDRESS <br /> CITY STATE zip <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 DIVISION 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 Ordlnanco Codes,Slandards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: G <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 0 <br /> IfAPPr c wr is not the BttyNG Pnm 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 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: <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVED <br /> c "' 1 222001 <br /> SAN JOAQUIN CCUNT`� <br /> PUBLIC HEAUH SERV!CE� <br /> ENVIRONMENTAL HEAL <br /> INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY:. EMPLOYEE#: (r�7DATE: <br /> ..ASSIGNED TO: MJ EMPLOYEE#: DATE: <br /> If <br /> Date Service Completed (if already completed): <br /> SERVICE CODE: IL�[P/E; <br /> Fee Amount. Amount Paid <br /> lP7 Payment Date <br /> � <br /> Payment Type Invoice# Check# �I <br /> 2„�T"� Received 8y: <br />