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} <br />I i SERVICE REQUEST <br />(—Typa of u mess Pop rty <br />I <br />FACILITY ID # <br />SERVICE REQUEST # <br />q-5-7 <br />111) 1& <br />�' -& J <br />OWNER/ 0 ERATO <br />BILLING PARTY <br />5 hiq <br />rFACILITY NAME <br />SS <br />SITE ADDREXI <br />. <br />(f <br />Street Number <br />Direction <br />► I l.v�i l/ <br />YV6treet Name <br />Type <br />Suite# <br />Mailing Address (If Different from Site Address) [I <br />b6 570 <br />CITY�m(6 <br />0 r- 0-% , <br />ST ZI� "f 53 i <br />& <br />PHONE #1 EXT. <br />AP �.. <br />LAND USE APPLICATION # 7 <br />c10 q —dG �2 <br />�$IVEDI <br />PHONE #2 f UT. <br />FEB 2 DISTRICT <br />J (IU�y <br />LOCATION CODE <br />S�Q <br />REQUESTr -- p SEF VICFC BILLING PARTY <br />BUSINESS NAME <br />�rkh 14 <br />PHONE#T <br />MAILING ADDRESS 2fiI o� <br />1 T 4�1— <br />CITY 1 Com( NL 1 <br />_ ATE zip <br />BILLING ACKNOWLEDGEMEL: 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 tnis project or activity Will be billed t0 me or my business as Identified on this form. <br />I also certify that I have prepared this olication 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 />CA <br />APPLICANT SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT �fl/ <br />If APPLICANT is not the BILLING PAR Tv 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 releas <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: �k�l <br />COMMENTS: <br />`?ECEIVED <br />FEB 23 2000 <br />SAN PUBLIC Ty <br />COUNTY <br />-:NVI,RoNMFI, EALTH SERVICES <br />INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: TA'L H �+ <br />AP'rnOVEDBY:I i EMPLOYEE #: I HATE: <br />AS:,IGNED TO- j EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: P 1 E:z� <br />I Fee Amount: O Zi Amount Paid Payment Date <br />i Payment Type Invoice # Check # Received B : f? <br />YP �°I y , <br />