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SERVICE REQUEST <br /> Type of Business orPygperty FACILITY ID# SERVICE REQUEST# <br /> �— <br /> WNERI OPTOR '/C�/O/` C BI� <br /> p v <br /> r <br /> WNG PARTY❑ <br /> .4021 J <br /> FACILITY NAME <br /> SITE ADORES <br /> m+l Nwnbrokm on SOM Niro Tryp� SUNe9 <br /> Mailing Address (If Different from Site Address) <br /> 't$ G <br /> CITY STATE ZIP <br /> b <br /> PHONE# Er. APN# LAND USE LIGATION? <br /> PHO #2 Err. OS DISTRICT - L TWN CODE..- ' <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REoUESTOR BILLING PARTY❑ <br /> qCILLING <br /> USINESS NAME PHOON�N'E# EIr. <br /> VJ i3V'j76 <br /> AILING ADDRESS FAX# <br /> try STATEZP ACKNOWLEDGEMENT: 1, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project speafic <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to me or my business as Identified on this forth. <br /> I also certify that I have prepared this application and Nat the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATUROWNEE: .[.Qr32��- DATE: _1 / <br /> PROPERTY/BUSINESSR OPERATOR/MANAGER ❑ OTHER AUfHORRFO AGENT <br /> IIAPPucwrisnotte�Burtcproorofwthariadon to sign is raquued Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,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 and/or emironmentalfsite assessment information to the SAN JOAQUI N COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OIVSION as Soon <br /> as it is available and at the same 6me it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> INSPECTOR'S SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY: EMPLOYI-- . - DATE <br /> ASSIGNED TO: EMPLOYEE#: DATE <br /> Date Service Completed (if already Completed): SERVICECODE -P I EL <br /> Fee Amount Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br />