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SERVICE REQUEST <br /> Type of Business or Property `��S FACILITY ID# SERVICE REQUEST# <br /> OWNER/ OPERATOR ` I <br /> JD 1 CHECK If KILLING ADDRESS <br /> FACILITY NAME CCC/// <br /> SITE ADDRESS <br /> Street Numb Direction SIreet Naa Type Suite# <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 1 , <br /> CITY n i7 ' STATfr, ZIF9 t 7 <br /> PHONE#1 EXT. APN# L-AND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR /J, � 1 <br /> c9 �Y CHECK if BILLING ADDRESS <br /> BUSINESS NAME /- PHONE# (���/ / ExT� ' <br /> HOME Or MAILING ADDRESS f� 1 � � ' n � fes# <br /> CITY ST <br /> CJ I ,_ <br /> BILLING ACKIOWLEDGEWNT: I, tl t r�5 ����r business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project sp `� RVICES ENVIRONMENTAL HEALTH DIVISION hourly charges <br /> associated with this pro ect or activity ill be s as identified on this form. <br /> I alsocertify that have pre s plicat performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinan e Codes,St E. <br /> APPLICANT'S S AT DATE: 1 <br /> PROPERTY/ BUSINESS OWNER O TOR i ;�j�'� 2AUTHORIZED AGENT <br /> If APPLIC.9NT is not the BILLING F I l n to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORIYL..wi.: when applicable, 1, 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: <br /> COMMENTS: 09 <br /> 'l I 5 -.�e 'I �• <br /> AUG 4 <br /> ,i4 IN <br /> �' ,'r N(✓;L'G HEALTH�;;,1UN1 Y <br /> cr - CONTRACTOR'S SIGNATURE: t::!VIRpt,I�&N' SERVICES <br /> INSPECTOR'S SIGNATURE: <br /> APPROVED BY: EMPLOYEE#: i DATE: (. <br /> ax <br /> ASSIGNED TO: EMPLOYEE#: /� �DATE: <br /> Date Service Completed (if already completed) i SERVICE CODE: I /r�� PIE: <br /> Fee Amount: ! Amount Paid j Payment Date <br /> Payment Type Receipt# I Check # Received By: <br /> SRREOrev.doc 7/1i1999 <br />