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V a SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# OWNER I OPERATOR BILUNG PARTY❑ FACILITY NAME SITE ADDRE/S-SS 3 1 V Stt..tNumber OlIecdon Mailing Address (If Different from Site Addressl Tie SUN@ I CITY STATE zip PHONE#1 APN# LAND USE APPLICATION# PHONE#Z EXT. 130S DuRicr aN C : OCAT DE:. CONTRACTOR/SERVICE REQUESTOR REQUESTOR BUSINESS NAME \ BILLING PARTY 0 r� PHONE# EXT, MAILING RESS FAX# CITY WTE b BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized Cagent of same, acknowledge that all site and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIvIsION hourly Charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance FEDERAL laws. with all SAN lOAQUIN COUNTY Ordinance Codes,Standards,STATE and APPLICANT SIGNATURE: DATE: PROPERTY/BUSINESS OWNER 0 OPERATOR/lAANAGER ❑ OTHER AUTHORIZED AGENT ❑ II APPLcmr is not the EUEVPAgTy proof of authorization to sign is Muirvd Title 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 any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DNISIoN as soon as it is available and at the same time it is provided to me or my represe tative. TYPE OF SERVICE REQUESTED: j )) COMMENTS: PAGE vE�D RE a�+N°°vtcE Sp�B�OE zP��HF 0"o ENVtRONM : INSPECTORS SIGNATURE: CONTRACTOR'S SIGNATURE: APPROVED DY.. EMPLOYEE#: DATE: ASSIGNED TO: EMPLOYEE#: G�!} DATE: Q Date Service Completed (if already completed): F� SERVICE CODE: a PIE: Fee Amount: ®p Amount Paid Payment Date np�„co�•� Payment Type Invoice#' �[ Check# b Received By: