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- SERVICE REQUEST <br /> FACILITY 10 9 SERVICE REQUEST <br /> FR <br /> Type of Business or Property <br /> BILLING PARTY 1-1 <br /> OWNER I OPERATOR <br /> FACILfTY117>k4E C <br /> a <br /> $ A DRES <br /> strw Humber Dlnctlan <br /> �/�V���TT�1111�+ rr SSttnnaMom. TY7a Swla1 <br /> Mailing Address (If Different from Site Address) <br /> STATE ZIP <br /> CITY <br /> PHONE #1 �• APN LAND USE APPLICATION# <br /> PHONE n2 <br /> Err. BIDS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> BILLING PARTY 0 <br /> RcnIIF.3TO� <br /> PHONE FX7' <br /> BUSKS AME ----- <br /> t FAx <br /> MAILING ADDRESS 0 <br /> STATE IP <br /> CrrY <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site andlor project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OtvtSION hourly charges assocated with this proleci or activity will be billed 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 a=rdance with all SAN JOAQUIN COUNTY Ordinance Codes,Slandards,STATE and <br /> • FEDERAL laws. <br /> DATE: <br /> APPLICANT SIGNATURE: <br /> PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER O OTHER AUTHORIZED AGENT 0 <br /> BAavtaGwr is not the 8 r�1r Pyr of autlrorrsatlon to slprt is npuQad <br /> i ill@ <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 and/or environmentaUSlte assessment into oration to the SAN JOAQUIN COUNTY PUeuC 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: - --- --- — -- - <br /> COMMENTS: <br /> APR 21999 <br /> SAN JOAQUIN Cvu"', <br /> VUBUC HEALTH SE',/ <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: I E![PLOYEE»: DATE' ' <br /> ASSIGNED TO: EMPLOYEE K: DATE: <br /> Date Service Completed (if already completed): Sc"RVICE CCDE: l PIE: l 2 <br /> O(' � OD I Payment Date <br /> Fee amount: Amount Paid <br /> Payment Type `� I invoice� <br /> Check Received By: <br />