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qP <br /> SERVICE REQUEST <br /> Typeof Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR �_ BILLING PARTY❑ <br /> L <br /> FAc1UTY NAMEMAW' CA 1(/J 4)O 1U 115 S � <br /> ' <br /> SITE ADORESS� ��U c l� r - Ttv <br /> Stnu Numbr INrtttion Strut NartN p� Suits i! <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE ZIP <br /> PHONE#1 APN# LAND USE APPUCAT1014# <br /> ( <br /> PHONE#2 <br /> err. BOS DIsTRIcr LOCATION COE-. <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR � BILLING PARTY❑ <br /> BUSINESS NAME PHONP# exL <br /> Manu AGREsslo -,w99 3 Fy/. 3 5 <br /> CRY �,7 �- II O fav✓ / t / STATE �• ZIP <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENViRONmENTAL HEALTH DimoN hourty charges associated with this project or activity will be tilled to me or my business as identified on this form. <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 /> DATE: <br /> APPLICANT SIGNATURE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT Q <br /> It APR-Cmr is not the O Lnc P rrm prod of autlrmUmdon to sign is mqu6d Ti t t e <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 environmentallsite assessment information b the SAN JOAOuw COUNTY Pueuc HEALTH SERVICES ENVIRoNmEmTAL HEALTH DwioN as soon <br /> as it is available and at the same tirne it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> GTU <br /> COMMENTS: <br /> PAYMItN <br /> JRECEI VE I <br /> 'AN a, 5206, <br /> SAN JOAQU!,NI t;.. <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: �� UPLOY--#: ql S /• DATE: <br /> ASSIGNED T0: EMPLOYEE#: - DATE: <br /> Date Service Completed (ff already completed): SERVICECODE: P/E: <br /> Fee Amountd�? Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> �7) AL1:6 r-,1, y�-. <br />