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SERVICE REQUEST EH0061SR revised 07/10/98 <br /> Type of Business or Property `a FACILITY ID# / S VI E REQU ST# <br /> OWNER/OPERATOR Xzb /� <br /> Jhp /,/!ti s !,'/�� BILLING PARTY El <br /> FACILITY NAME �1 �L �S�, <br /> SITE ADDRESS // % �'/JCA: <br /> StreetNumilet (•Direction a"6L,61me"L/ Type Suite# <br /> Mailing Address (If Diff t from Site Addre�ssl <br /> CITY — n <br /> MT , ZIP <br /> PHONE#1 EXT• APN# LAND USE APPLICATIONI's Q - n 00 " FI <br /> # <br /> o , <br /> PHONE#T. Ext BOS DISTRICT LOCATION CODE <br /> 0 9 <br /> SoL --7 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY <br /> I <br /> BUSINESS NAME PHONE# ExT• <br /> MAILING ADDRESS _ FAX# <br /> CITY STATE ZIP <br /> �J C � <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site <br /> and/or project Specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project Or activity will be billed to <br /> me or my business as identified on this form. <br /> I also certify that I have pflpared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br /> Ordinance Codes, Stand $,}S,cT,AT�E. and FEpERAL la <br /> APPLICANT SIGNATURE: C+� y L�-C CJ /1��� DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING,PARTY 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, <br /> hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY <br /> 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. <br /> TYPE OF SERVICE REQUESTED: j <br /> COMMENTS ❑ SPECIAL CONDITION(S)OF APPROVAL❑ OTHER ❑ <br /> PAYMLI <br /> APRAPR 1 3-1M9 A LI, -- - -- <br /> 9AN JOAQUIN WUN'r <br /> ENVIRONMEtT"IV DMS <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: I DATE: <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED T0: Q j,� EMPLOYEE#: `:3 C�(✓ DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E:2C3 <br /> Fee Amount: Z Amount Paid 2 J Payment Date /-� Y <br /> Payment Type Invoice# Check# Received By: <br /> E <br />