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SERVICE REQUEST <br />Type of Business or Property <br />BILLING PARTY 0 <br />FACILITY ID # <br />SERVICE REQUEST # <br />WNE PERATOR <br />BUSINESS NAME <br />BILLING AR <br />FACILITY NAME <br />PHONE- # EXT. <br />SITE ADDRESS <br />1 e� v Strlet Number <br />Direction <br />7 —�stnate Name <br />Type <br />Suh <br />Mailing Address (If Different from Site Address) <br />FAX # <br />C � � <br />STATE ZIP <br />PnnHON�E}#1 <br />CITY <br />APN # <br />t ANO USE APPLICATION # <br />PHONE #2 <br />EXT. <br />1 <br />BOS.DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />11 <br />REQUESTOR <br />BILLING PARTY 0 <br />PAYMENT <br />BUSINESS NAME <br />�-- �— <br />PHONE- # EXT. <br />SAN JOAOUIN COUNTY <br />PUBLIC <br />`DI�iICr <br />ENVIRONMENTALLHEAL HTH <br />SION <br />MAIL ORES <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY:. \IAe� <br />�� VV VVvv <br />FAX # <br />EMPLOYEEID� <br />DATE: �I D <br />ASSIGNED TO: <br />l <br />CITY <br />EMPLOYEE 9:M <br />ST E ZIP9��� <br />BILLING ACKNOW GEMEN , the odeigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific <br />PUBLIC HEALTH SERvicS IRON ORtToorl}rcharge ociated with this projector activity will be billed tomo or my business as identified on this form. <br />I also certify that I hay e a i ap licati n d that the work to be performed will be ne in a000rdance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and <br />FEDERAL. laws. <br />APPLICANT SIGNATURE: — DATE:. - <br />PROPERTY I <br />ATE:__PROPERTY! BUSINESS OWNER O OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT O' <br />tfApmcwr is not the Bu ►�c Purry proof of authodzsUon to sign is rmquirod Ti t f e <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, i, the owner or operator of the property located at the above site address, hereby authorize Lye release of <br />any and all results, geotechnical data and/or environmentallsile 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: <br />N <br />COMMENTS: <br />PAYMENT <br />RECEIVED <br />JAN 1 6 2001 <br />SAN JOAOUIN COUNTY <br />PUBLIC <br />`DI�iICr <br />ENVIRONMENTALLHEAL HTH <br />SION <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY:. \IAe� <br />�� VV VVvv <br />EMPLOYEEID� <br />DATE: �I D <br />ASSIGNED TO: <br />l <br />EMPLOYEE 9:M <br />DATE: <br />Date Service Completed (if already completed):SERVICECODE: <br />1 <br />P 1 E: <br />Fee Amount: r- <br />Amount Paid ,� <br />Payment Date <br />Payment Type Invoice #' <br />Check ax > <br />Received By: <br />