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SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# OWNER I OPERATO / BILLING PARTY❑ eW FACILITY NAME SITE ADDRESS � � /�� Strep Numb.r elr�ecton �� Name Type Suits Mailing Address (If Different from Site Address' CITY ` �p,/ ' STATE Zip PHONE#1 < EXT. APN# LAND USE APPLICATION# PHONE#2 �T• LOCATION CODE P��-117CT CONTRACTOR/SERVICE REQUESTOR REQUESTOR BILLING PARTY 0 BUSINESS NAME PHONE# Exr. MAILING ADDRESS J 17 FAX# CITY STATE Zip BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific PUBLIC HEALTH SERVICES ENvtRDNMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to me or my business as identified on this corm. 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 Ordinanco Codes,Standards,STATE and FEDERAL laws. 7 APPLICANT SIGNATURE: DATE' PROPERTY I BUSINESS OWNER ❑ OPERATOR/MANAGER� ElOTHER AUTHORIZED AGENT .� IfAPPt rwr is not the Bun+c EAm-Y,proof of authorization to sign is requirodd' 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 environmentattsile assessment information to UTC SAN JOAQUIN COUNTY PUBLIC HEALTH SERvicrs ENVIRONMENTAL HEALTH DlvlsiON as soon as it is available and at the same time it is provided to me or my representative. TYPE Of SERVICE REQUESTED: INSPECTORS SIGRATURLO CONTRACTOR'S SIGNATURE: APPROVED f4Y:. i p, EMPLOYEE#: Z-, I DATE: L, ASSIGNED TO: 17 ® � EMPLOYEE 9: u'! DATE: Date Service Completed ((f already completed): 7 SERVICE CODE: G'.� PIE: Fee Amount: =` Amount Paid L" Payment Date ) 6 1 Received By: Payment Type Invoice# he �,,/