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w SERVICE REQUEST r Type usiness r Property FACILITY iD # SLI HEALTH RICES ENV O ENTAL SERVICE REQUEST # C 8-6::�� BUSINESS NAME `Z 3,— OWNER / OPETORI r N U / �J L CHECK If BILLING ADDRESS iT �/ / FACILITY NAME P / E: HOME or MAILING ADD SS� FAX#/� SITE ADDRESS/ ✓% / V-A, C�` v / �reet Check # Street Number Direction Nar' e Suite # HOME Or MAILING ADDRES/,�I (If Different from Site Address) L `� k r/ CITY STAT ZIP PH�E #) �3 �/��„ E"T• •--lsJ� APN # LAND USE APPLICATION # ' . 1 t7/f PHONE #2 ( ) ExT. BOS DISTRICT LOCATION CODE CONTRACTOR I SERVICE REQUESTOR BILLING AC104OWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific 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. 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 Ordinance Codes, Standard.I, ST.� and FEDERAL last's. APPLICAINT'S SIGNATURE: DATE: li PROPERTY/ BUSINESS OWNER P JOR / NIAi•IAGER) V OTHER AUTHORIZED AGENT If APPLICANT is ;tot the LING PARTY r of authorization to sign is required Title 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 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 as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: REC'EWED RUSH REQUESTOR CHECK if BILLING ADDRESS SLI HEALTH RICES ENV O ENTAL f C j EMPLOYEE #: O BUSINESS NAME Date Service Completed (if already completed): PH ^ ^ E P / E: HOME or MAILING ADD SS� FAX#/� 35r' _ CITY n„ STATE ZIP BILLING AC104OWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific 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. 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 Ordinance Codes, Standard.I, ST.� and FEDERAL last's. APPLICAINT'S SIGNATURE: DATE: li PROPERTY/ BUSINESS OWNER P JOR / NIAi•IAGER) V OTHER AUTHORIZED AGENT If APPLICANT is ;tot the LING PARTY r of authorization to sign is required Title 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 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 as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: REC'EWED RUSH AUG 12 1M EMPLOYEE #: SLI HEALTH RICES ENV O ENTAL f ALT DIVISION LINSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: I ) ` Il SRREQrev.doc 7/1/1999 APPROVED B EMPLOYEE #: DATE: I -Z f ASSIGNED TO: j EMPLOYEE #: O DATE: n L� Date Service Completed (if already completed): SERVICE CODE: i P / E: Fee Amount: Amount Paid 35r' _ i Payment Date Payment Type ✓ ! Receipt # Check # I Received By: SRREQrev.doc 7/1/1999