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• SERVICE REQUEST <br /> Type of Susi s or Prope FACILITY ID# SERVICE REQUEST# <br /> 006 5/�. 00250-'.23 <br /> OWNER/OPE BILLING PARTY D <br /> FACILITY NAME <br /> SITE ADDRESSS� {}) <br /> l.(//R Street Number Direction //(� Name Type Suite# <br /> Mailing Address (If Different from Site Address) <br /> CITY A/ STATE ZIP <br /> PHONE#9 Y EXT. APN# LAND USE APPLICATION# <br /> i ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 1 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUEST BILLING PARTY L <br /> BUSINESS NAME � ,^� PHO NE# EXT. <br /> MAILING ADDRE S^ � • �V�• FAX# <br /> 4 � <br /> CITY TATE ZIP a <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 islapplicatio,, that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. f U <br /> APPLICANT SIGNATURE: I DATE:— <br /> PROPERTY/ <br /> ATE:PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT I <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,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 meormy representative. <br /> TYPE OF SERVICE REQUESTED' - <br /> COMMENTS: <br /> PAY <br /> RECi: <br /> JAN <br /> SAN JOAQ�, <br /> PUBLIC HEAL <br /> ENVIRONMENTAL n. <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EMPLOYEE#: c y tiQ � DATE: 1 <br /> ASSIGNEDTO: l� EMPLOYEE#: V C� DATE: <br /> Date Service Completed (if already completed): rJ SERVICE CODE: Ct' P/E: <br /> Fee Amount: Z Amount Paidt• �� Payment Date 'p <br /> Payment Type Invoice# Check# 5 V Received By: <br />