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SERVICE REQUEST <br /> SERVICE REQUEST <br /> ype of Business or Prope FACILITY ID R <br /> OWNS. I OPERATOR BILLING PARTY <br /> FACILITY VAME S <br /> SITE ADDRESS <br /> Str•cc Humnr Dlr•cUon �jp•E • TYO• Swl•! <br /> Mailing Add ss (if Different from Site Address) <br /> STATE �^ ZIP <br /> CrT r <br /> PHONE 91 ExI APN# LAND USE APPLICATION# <br /> t� <br /> PHONE#2 UT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> / �O�D,� BILLING PARTY O <br /> R=_^y7kz4a.L4 <br /> tel. L—�.J <br /> BUSINESS N EPHO% # EXT. <br /> 5_ _. FAx# S � <br /> MArUV7-3� <br /> S "CITY ' STATE (Z Q ZIP <br /> �r <br /> BILLING ACKNOWLEDGEMENT: I, the unaersigned property or business owner, operator or authorized agent of same, acknowledge that ail site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges assocated 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 prepared this appiicadon and that the to be p riormed will be done in accordance with all SAN JOAQUIN COUNTY 0 finance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: —�� <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER 0 OTHER-AUTHORIZED AGENT 0 <br /> UAPm mrisnotrheBu#nPARrvproofofauthonzadontosignisraqukW 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 ana/or envtronmentallsite assessment into mation to the SAN JOAQUIN COUNTY PuBUC HEALTH SERVICES ENVIRONMENTAL HEALTH DrvISION 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: / - <br /> �/ <br /> COMMENTS: PA Y <br /> APR 2 2 1 <br /> bAN�JOAQUIN r:VWrl+tI i <br /> PUBLJC HEALTH 61 PMIDi": <br /> t_NVIRONMFNTAI. HIr.A1`1i4 <br /> INSPECTOR S SIGN R NTRACTOR'S SIGNATURE: <br /> APPROVED BY: I ESIPLOYEE R: <br /> EMP <br /> DYE=- <br /> K: �✓ G DATE: <br /> ASSIGNED 70: <br /> Date Service Completed (If already completed): SERVICE CODE: <br /> /,�/ I amount Paid C <br /> Fee ?,mount: Payment Date: ' <br /> CID <br /> Pavment Type invoice <br /> Check Received By: <br />