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SERVICE REQUEST db <br />Business or Property <br />c— 111:( cnl -_s; 1, ,C <br />FACILITY ID # <br />SERVICE REQUEST # <br />S NAME , a <br />IVO 3S Z <br />MAIL G ADDRESS <br />/OPERATOR <br />/7� /� <br />// ♦ <br />CHECK if BILLING ADDRESS O <br />(aolr ) :F's 1 � <br />PUBLIC HEALTH SERVICES <br />STATE ZIP <br />TAME r <br />APPROVED BY: <br />EMPLOYEE #: C�(p <br />GG <br />DATE: fJ d <br />ASSIGNED TO: ���J . c' c _ / <br />✓already <br />EMPLOYEE #: <br />�y L <br />RESS <br />Date Service Completed (if completed): <br />/fir /C Cil <br />SERVICE CODE:®l7 1 <br />P I E:'0 <br />U <br />Fee Amount: /2 <br />Amount Paid <br />Street Name <br />Payment Date <br />Tyve <br />Suite # <br />MAI ING ApDRESS (If Different from Site Address) <br />Check # ZO° <br />Received By: <br />G.0 <br />STATE <br />ZIP <br />XT. <br />APN # <br />LAND USE APPLICATION # <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />iTOR <br />c— 111:( cnl -_s; 1, ,C <br />COMMENTS: <br />CHECK if BILLING ADDRESS AL1 <br />S NAME , a <br />PHONE # EXT. <br />RECEIVEL) <br />MAIL G ADDRESS <br />FAX # <br />z` G <br />(aolr ) :F's 1 � <br />PUBLIC HEALTH SERVICES <br />STATE ZIP <br />IG ACIAWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />ledge that all site and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges <br />-d with this project or activity will be billed to me or my business as identified on this fon-n. <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 <br />OUNTY Ordinance Codes, Standards, STATE an <br />APPLICANT'S SIGNAT DATE:(j Zr « �) <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR NAGER ❑ OTHER AUTHORIZED AGENT <br />P 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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and <br />at the same time it is provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: � / — ��l,s <br />c— 111:( cnl -_s; 1, ,C <br />COMMENTS: <br />PAYM ENq <br />RECEIVEL) <br />FE3 12 20, <br />SAN JOAQUIN COUNT% <br />PUBLIC HEALTH SERVICES <br />rNVIRONMFNT;,I HFI�I_Tf' DIVI�'� <br />APPROVED BY: <br />EMPLOYEE #: C�(p <br />GG <br />DATE: fJ d <br />ASSIGNED TO: ���J . c' c _ / <br />✓already <br />EMPLOYEE #: <br />�y L <br />DATE: <br />Date Service Completed (if completed): <br />SERVICE CODE:®l7 1 <br />P I E:'0 <br />U <br />Fee Amount: /2 <br />Amount Paid <br />---T- <br />Payment Date <br />�� ,� a� <br />Payment Type v/ t 6�1 <br />Receipt # <br />Check # ZO° <br />Received By: <br />EH 48-01-010 <br />7/1/1999 <br />J�� <br />