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10 SERVICE REQUEST 0 <br />N. <br />r <br />GUN I KAG I UK 1 JCKvIt.c M=%AW GJ 4 — <br />REQUESTOR <br />✓/ <br />BUSINESS NAME <br />PHONE # <br />BILLING PARTY ❑ <br />W. <br />FAX # <br />MAILING ADDRESS 7 7 <br />Ern STATE 7P rZ `/GO <br />Ze <br />BILLING ACKNOWLEDGEMENT: 1, the Undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project spec:c <br />PueuC HEALTH SERvicES E.WRGNMENTAL HEALTH ONistoN hourly charges associated with this project or activity will be billed to me or my business as identified on this form. <br />1 also certify that I have prepared this and th will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and <br />FEDERAL laws. q O-3 <br />APPLICANT SIGNATURE,apLpllon <br />DATE' / <br />PROPERTY / BUSINESSC OP GR I MANAGER �E' AUTHORIZED AGENT T itle <br />IfAa not the ljL� PAM proof of audnria6on to sign is requiredAUTHORIZATION TINFORMATION: When appli ble, 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 andlor environmentailsite assessment information to the SAN JOAQUIN COUNTY PueuC 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 SERvia REQUESTED: (`� �'� (�a�r D <br />COMMENTS: ��1 {\J�1� <br />SPBU�NtiP NF��t�\��`��t1N <br />ENVIR�NMFNj�� <br />CONTRACTOR$ SIGNATURE: <br />INWItI.I UK J Q1%3� <br />APPROVED BY: �� �` <br />EMPLOYEE #: <br />ASSIGNED TO: S <br />EmpLOYEE;#: <br />Date Service Completed (if already completed): <br />FeeAmount: �O <br />Amount Paid <br />Payment Type <br />Invoice # <br />C <br />DATE: <br />13 s o DATE: 12 <br />SERVICE CODE: - <br />Payment Date <br />ledt # ,�(1 <br />61 <br />-PIE: <br />Received By: <br />