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1 <br /> SERVICE REQUEST _ EH0061SR revised 07/1 <br /> --fType of Business or Property FACILITY ID# r SERVICE R Q # <br /> IN i to►-1 <br /> OWNER I OPERATOR C i ` ! BILLING PARTY L7 <br /> FACILITY NAME N�j <br /> �G <br /> SITE ADDRESS 7 I L� P-Q <br /> • If •f•� , Lim rpa Suifea <br /> -street N{mber Direction <br /> Mailing Address (If Different from Site Address) <br /> CITYSTATE CA zip 96376 <br /> PHONE#1 <br /> C Exr. APN# LAND USE APPLICATION# <br /> - ao9-$3�-34r6 <br /> PHONE#T En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> BUSINESS NAME P O E# _ ^ OO r <br /> L L �� <br /> MAILING ADDRESS FAX# �✓ <br /> d o X37' 1� <br /> STATE zip i�� y x <br /> C11Y o t\l�� t V'r S V J <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site <br /> and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to <br /> me or my business as identified on this form. <br /> I also certify Ihat a red this applic tion end that the work to be performed will be done in accordance with all SAN JOAQvtN COUNTY <br /> Ordinance Codes, Standa , TATE and FED L laws. I <br /> APPLICANT SIGNATURE: 'rC DATE: 1I <br /> PROPERTY/BUSINESS OWN C:—�Op / ANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPucArrr is not the BxLrNG PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, I, the owner or operator of the property located at the above site address, <br /> hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the sam time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> Ti) Ia5-TAlk 0, is P ..5.;: all <br /> COMMENTS ❑ SPECIAL CONDITION(S)OF APPROVAL❑ OTHER ❑ <br /> INSPECTOR'S SIGNATURE: I CONTRACTOR'S SIGNA D <br /> APPROVED BY: - EMPLOYEE DATE: <br /> vv- v ' <br /> ASSIGNED TO: - �. EMPLOYEE#: DATE: <br /> L <br /> Date Service Completed of already completed): SERvicE CODE: P 1 E: Z <br /> Fee Amount o e nO Amount Paid Payment Date <br /> Payment Type Invoice# Check# C7 Received By: <br />