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6 SERVICE REQUEST 16 <br />T e of Busines oqProperty N <br />FACILITY ID #o <br />� <br />SERVICE REQUEST # <br />OVYNAZ I OPERATOR <br />Jj <br />tttt <br />SAN JOAQUIN COUNTY <br />BILLING PARTY ❑ <br />FACILITY NAME 0 -up, <br />OuAPM <br />APPROVED BY:. <br />EMPLOYEE #:.\ lav <br />Vv <br />SRE � ORE <br />StrfetNumber <br />1-- 7-1�••-( <br />DATE: <br />SVKlNxni�.. e <br />SERVICECODE: q $ <br />Type <br />SvIU! <br />Mailing Address (If Different from Site Address) -P. <br />Received By.. <br />CITY lb <br />t A/� � <br />�/�J <br />STATE <br />�J a r� <br />/.\ ( J <br />HONE #1 <br />Pvo <br />ExT• <br />34 <br />APN # <br />LANO USE APPLICATION # <br />PHONE #2 <br />( <br />BOS,DISTRICT <br />LOCATION CODE <br />n CONTRACTOR I SERVICE REQUESTOR <br />REQUESTORI j� � \ <br />BILLING PARTY ' <br />BUSINESS NAM <br />GL <br />s <br />PHONE# �T• <br />MAILING ADDR SSS ✓ <br />SAN JOAQUIN COUNTY <br />FAx # — / <br />4 <br />CRY / <br />ZIP <br />STATEUCY <br />BILLING ACFCNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge tlat ail site and/or proved speafc <br />PUBLIC HEALTH SERVICES EI%ONMENTAL HEALTH DMSIoN hourty charges associated with this project or activity will be billed to me or my business as identified on this form. <br />I also certify that I have repart}d this application and at the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinanco Codes, Standards, STATE and <br />FEDERAL laws. 1 <br />APPLICANT SIGNATURE: DATE: - <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT <br />Il Avpm.wr is not the f i -m Purry proof of authorizatlon to sign Is requirod 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 release of <br />any and all results, geotechnical data and/or environmental/sile assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DNISION 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: q6 <br />COMMENTS: <br />PAYMENT <br />RELIVED <br />OEC 212091 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISIi;I, <br />INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br />APPROVED BY:. <br />EMPLOYEE #:.\ lav <br />Vv <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE 9: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICECODE: q $ <br />P I, 3� <br />Fee Amount: © Amount Paid Payment Date 1221 l 6 > <br />Payment Type Invoice #' Check 4 �J 03 <br />Received By.. <br />Mon <br />