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SERVICE REQUEST <br /> Typoo Business or Prop rtyj / ` 7 FACILITY <br /> ,ID�# SERVICE REQUEST 9 <br /> OWNE ",PEAT EILUNG PARTY 0 <br /> FACILITY NAME yy � �, <br /> SITEADDRESS <br /> /✓! StrectNwnbor Dlrecton J ✓ [-aLi�SyMNbn. Type suites <br /> Mailing Address (If Different from Site Add ess <br /> C fTYj I/ lJ 0( <br /> PHONE#1 C !!C� EXI• APN# LAND USE APPLICATION# (� <br /> 'X" BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTO BILJNG PARTY <br /> TASV C / <br /> BUSINESS NAME ► � PHONZ# <br /> MAILING ADDRESS FAX# <br /> CITY } I TATE zip /7 r <br /> BILLING ACKNOWLEDGEMENT! f, the undersigned property or business owner, operator or authorized agent of same,acknowledge thal all sile and/or project specific <br /> PusuC HEALTH SERVICES ENVtRGNmENTAL HEALTH DivislON hourly charges associated with this project or activity will be billed to me or my business as identified on this form. <br /> I also"lly that I have prep r>,this application and that the work to be performed will be done in accordance with all SAN JOAOUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: ��_✓L ���/ / DATE: <br /> PROPERTY IBuswESSOWNER ri OPERATOR I MANAGER D OTHERAUTHORi7EDAGENT In.,: <br /> frAPPUC.wr is not the Q�-res Purrs proof rulhorizatlan to algn is roqulmd Title <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 oI <br /> any and all results,geotechnical data andlor environmentallsite assessment information to the SAN JOAQUIN COUNTY PUGLIG HEALTIt SERVICES ENvIRONMCNTAL HEALTH ONISIoN as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE 41=SERVICE REQUESTED: <br /> COMMCNTS: <br /> PAYMEN F <br /> RECENED <br /> a �mfl� <br /> AN IJ IJCiUiNT <br /> INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY:. �J EMPLOYEE#; DATE: <br /> ASSIGNED T0; co'-4aV , EMPLOYEE#: -j I DATE: <br /> Date Service Completed (if already completed): 11 SERVICE CODE: <br /> Fee Amount: (�, � Amount Paid �. 7Payment Date ! 31 <br /> Payment Type Invoice n' Check# �'/�'/-3 Received By: <br />