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ti <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> v <br /> OWNER OPERATOR BILLING PARTY 0 <br /> FACILITY NAME <br /> At IJ D L 'TrZ u C K <br /> SITE ADDRESS <br /> G'rl,/ �>t� <br /> Street Number Olrecoon sued rr. N>„ne <br /> TYpe Svlt�! <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE Zlp <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 En. BOS.DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR ^ )n f / <br /> JC/v BllllNc PARTY p <br /> BUSINESS NAME 1/ PHONE# Ext. <br /> MAILING ADDRESS FAX# <br /> CITY <br /> STATE C� ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or proiect specific <br /> 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. <br /> I also certify that I have prepared this PI tion and thajVq work to be performed will be done in acwrdance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: L� V <br /> PROPERTY/BUSINESS OWNER ❑ 40PETORIMANAGER ❑ OTHER AUTHORIZED AGENT <br /> IIAPM-r wr is not Cie kUk Pura proof of authorization to sign is required Title <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 environmental site assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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: G <br /> %., i L S c /Tj{ a/L / %Z+v y lel t/"j ltc-t/ <br /> COMMENTS: <br /> PAYM E N t <br /> RECEIVED <br /> am 2 <br /> SAry jOAUUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISIOr! <br /> INSPECTOR'S SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED 13Y:.---- <br /> IEMPLOYEE#: 0(�� DATE: <br /> ASSIGNEDTO: EMPLOYEE#: Y DATE: <br /> Date Service Comp ted (if already completed): <br /> SERVICE CODE: PIE: <br /> 1 <br /> Fee Amount: Amount Paid 6, - IPayment Date 1 <br /> Payment Type Invoice 4' Check# <br /> Received By: <br />