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• • SERVICE REQUEST • <br />Type of Busines pr Property <br />�' <br />FACILITY ID # <br />� <br />SERVICE REQUEST"" <br />�-►� <br />RECEIVE <br />PACE vED <br />L �,.�� �-- <br />OWNER I OPERATO 0. J <br />r <br />BILLING PARTY <br />12 2000 <br />J�t� <br />utAIN <br />GD`hC.r�, <br />FACILITY NAME 1.1 <br />cli <br />jOAp��N <br />SITE ADDRESSv <br />53 <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />ArrmuV'D BY: <br />Street Number <br />Direction <br />V <br />Street Name <br />1. <br />Type <br />Suite# <br />Mailing Address (If Different from Site Addre I <br />DO Ly�)�, <br />(, <br />Date Service Completed (if already completed): <br />CITY / j� <br />_ <br />ST,4E <br />ZIP r <br />PHONE #1 EXT. <br />APN # <br />Payment Date Z <br />LAND <br />USE APPLICATION # <br />`J <br />Check # l LE3 (� <br />Received By: <br />PH E ,�^ I Di <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR I SERVICE REQUESTOR <br />BUSINESS NAME <br />BILLING PARTY ❑ <br /># LEXT. <br />MAILING ADDRESti f <br />t <br />CITY ESTATE ZIPI <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 changes 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 prepare is application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and <br />FEDERAL laws. <br />APPLICANT SIGNATURE: Qll/ �. L �V(�/ / DATE' <br />PROPERTY; BUSINESS OWNER 11 OPERATOR I MANAGER El OTHER AUTHORIZED AGENT L <br />YAPPucANT is not the BiuiNG PAR ry 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 environmentaVsite assessment informati0n 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 />n' <br />RECEIVE <br />PACE vED <br />12 2000 <br />J�t� <br />utAIN <br />GD`hC.r�, <br />SpN Jr, <br />jOAp��N <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />ArrmuV'D BY: <br />EMPLOYEE #: �(1 <br />I r)erc• <br />- <br />ASSIGNED TO: <br />EMPLOYEE#: �ue) I <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE:I <br />P 1 E: <br />Fee Amount: �;3114 — <br />Amount Paid 1vt © <br />Payment Date Z <br />16-0 <br />j Payment Type G��� <br />Invoice # <br />Check # l LE3 (� <br />Received By: <br />