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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE PEQUFrST#`J/ <br /> -3cam,. ' e- �1 111 I <br /> OWNER/OPERATOR BILLING PARTY❑ <br /> FACILITY NAME Al ' <br /> SITEADDRESSSS / <br /> o Q G� Street Number Direction vt C— /+ Street Name (�' _ Type Suite 0 <br /> Mailing Address (If Different from Site Address) <br /> CITY • STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR . !- Y BILLING PARTY <br /> BUSINESS NAME /� PHONE# EXT. <br /> (ZO ,7 Z 3 `f Z S o <br /> MAILING ADDRESS j �d FAX# <br /> /, L, <br /> CITY /' ` STATE C zip S 3 O <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site andlor project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly Charges associated with this project Or activity will be belied to me or my business as Identi`ed on this fort. <br /> 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,Standards,STATE and <br /> FEDERAL laws. /, ` <br /> APPLICANT SIGNATURE: L `' DATE: <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT x- <br /> �— <br /> If APPucavr is not ft fti wg PA ary proof of authorization to sign is reGuirid Ti t7 <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 environmental/site assessment information to the SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVIS!ON 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: /� J `p <br /> COMMENTS: PAYMENT <br /> ,452 RECEIVED <br /> �V 9INOW <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. �� � v�� EMPLOYEE#: 6,4j-6 DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: )."16 P I E: 23 06 <br /> Fee Amount 2��� Amount Paid 23� Payment Date f ", 9 <br /> Payment Type Gl� /G Invoice# Check# 7503 Received By: <br />