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SERVICE REQUEST '`W <br /> Type of Business or Property FACILITY[D# <br /> SERVICE REQUEST# <br /> OWNER I OP TOR ! i <br /> BILLING PARTY 0 <br /> FAcmTY NAME <br /> SITEADDRESS a <br /> �•/ Street Numtyer Orrectian �!'-'i>YT 1 �� •�-' <br /> TTPe Suite <br /> Mailing Address (if Different from Site Address) Strw Nave <br /> CITY <br /> Vl tl " STATE zip <br /> YYY111 � /f <br /> PHONE 91 APN# LAr1l USE APPUCATION# <br /> PHONE#2 BOS:DlSTRSCT - <br /> t_OCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BIUJNG PARTY <br /> /K <br /> BUSINESS NAme h PHONE-# Exr, <br /> 4 © _ i <br /> MAILING ADDRESS FAX# <br /> CIT 7 /I STATE /f zip <br /> BILLING'ACMNOWLEDGEMENT: I, the undersigned property or business owner, operator.or authorized agent of same, acknowledge that an site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTN DWISION hourly charges associated with this project or activi:y will be billed to mo or my business as Identifiedon this tonTL <br /> I also certify:hal I have prepared this plication and the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinanca Codes.Standards.STATE and <br /> FEDERAL laws <br /> APPUCAHT SIGNATURE' / <br /> DATE: /��v CXJ --76Ci O <br /> PROPERTY IBUSINESS OwNER ❑ OPERATOR INL AGER 0 OTHER AUTHORIZED AGENT <br /> IrAPPLcmris not ft ULLgQpAqTy,proof ot-lurhorizardon ro srQn Is nqurrvd true <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable. I,1110 owner or operator of the property located at the abova site address,hereby autherizo the release of <br /> any and all results;geotechnical data and/or environmentallsile assessment information to the SAN JOAOUIN COUNTY PUBLIC HEALTH SCRVIc[S ENVIRONkiENTAL 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 SERv10E REQUESTED: - {'��j <br /> , v <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVED <br /> N O V 2 $ 2000 <br /> SAN JOAQUIN CUNT, <br /> PUBLIC HEALTH SERVICES` <br /> ENVIRONMFNTAI HEALTH DViSfo!'- <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. EMPLOYEE#: DATE: <br /> EAssGNED•T0:' EMPLOYEES: '� DATE: <br /> d (if alt� dy completed): <br /> p SERVICE CORE: <br /> Date Service Completed <br /> PIE:.7—,. � <br /> Fee Amount. . M <br /> Amount Paid Payment[date <br /> I1/ C <br /> Payment Type Invoice#' 1 Check 0 <br /> 3S S Received By: <br />