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SERVICE REQUEST EH0061SR revised 07/10/98 <br /> Type of Business or Property FACILITY ID# SERV E REQU T# <br /> 1 <br /> OWNER I OPERATOR BILLING PARTY❑ <br /> FACILITY NAME LaV (�,C) <br /> t �D <br /> SITE AD R <br /> 0 StrLtNumber D'recfion St a Type Suite# <br /> Mailing Address (If Different from Site Address) <br /> CRY O STATE ZIP <br /> _f. og#1q � EXT. APN# LAND USE APPLICATION# <br /> ef 0�) qA — <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR I <br /> BILLING PARTY <br /> BUSINESS NAME PHONE# EXT. <br /> ELM i ZZ— <br /> MAILING ADDRESS FAX# <br /> CITY C� / STATE ZIPS <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 prepared this applicati n and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br /> Ordinance Codes, Standard a EDY laws. r <br /> APPLICANT SIGNATURE: ' DATE: !/J/,/ <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORI GENT < !�' <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is requir d Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, 1, 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: - <br /> COMMENTS ❑ SPECIAL CONDITION(S)OF APPROVAL❑ OTHER ❑ <br /> PAYMENT <br /> ----- -- -- --- DEC 10 1998 - <br /> SAN JOAQUIN COUNTY <br /> _._.--..--..................._........-- —.— —...-—---- .... ----....---------------- <br /> ENVIRONMENTAA1_TCfiSETti%iZ`T�'�_-'--- <br /> L HEALTH ul'ViSIONi <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: DATE: <br /> APPROVED BY: .` EMPLOYEE#: DATE: <br /> �. CJ <br /> ASSIGNED T0: M310 <br /> EMPLOYEE#: / f( DATE: �� U <br /> Date Service Completed (if already completed): SERVICE CODE: Lj�--'C P I d�- <br /> Fee Amount: o ( b Amount Paid Payment Da �L /M <br /> Payment Type Invnice# Check e x Received By: <br />