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f <br /> SERVICE REQUEST <br /> r <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR BILLING PARTY❑ <br /> FACILITY NAME <br /> SITE ADQRESS L <br /> Strret Number Oinettion Strsa Name T"M Suite• <br /> Mailing Address (If Different from Site Address) <br /> CITY $TA ZIP <br /> PHONE#1 Err. APN# LAND USE APPLICATION# <br /> (aftpi) t�� �S�4 <br /> I T <br /> PHONE#2 BOS DISTRICT LocnoN CODE <br /> 7 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR i� BILLING PARTY <br /> BUSINESS NAME \� �do`\�1= � j PHONE# ^a Err. <br /> MAILING ADDRESS \ FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner,operator or authorized agent of same, admowledge that ail site and/or project specific <br /> PUBuc HEALTH SERVICES ENVIRONMENTAL HEALTH ONLSION hourly Charges associated with this project or activity will be billed to me or my business as identified on this form. <br /> I also certify that I hav, prepa this Ica. and that the to be performed wit be done lo accordance with all SAN JOAQUN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. f <br /> APPLICANT SIGNATURE: ) DATE: <br /> PROPERTY/BUSINESS ❑ OPERATOR/MANAGER Cl OTHER AUTHORIZED AGENT <br /> If ApperCwr is not the Sx �G Purry proof of Kvw ftvdon to syn is nquiw \ 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 of <br /> any and all results,geotechnical data andlor environmeniallsite assessment infomWtion tD the SAN JOAQUN COUNTY PUBLIC HEALTH SERVICES ENVIRONhENrAL HEALTH DWiON 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 /> A <br /> COMMENTS: <br /> PAYME -�e <br /> 1 <br /> PFr—rF FD <br /> FEB 191999 <br /> it. ..J._��.,•.raUty T�( <br /> �M NfAL HEi;LTH©iVISi " <br /> INSPECTOR'S SIGNATURE: CO c o <br /> APPROVED BY: . .r C`!Z) f DATE. 2 C,C, <br /> ASSIGNED TO: I ` EMPLOYEE#: ? C) DATE: `� 1 <br /> Date Service Completed (ff already completed): SERVICE CODE: P f E:� <br /> Fee Amount: �j 0�, Amount Paid ' a ' L,4 Payment Date <br /> Payment Type Invoice# Check# a O o4 9 <br /> Received By: �j <br />