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SERVICE REQUEST <br /> D EST <br /> Type of Business or Property FACILITY ID# <br /> SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> LU�^ �� � y ` �� l BILLING PARTY S-'FACILITY NAME , <br /> 4,L_vC)`r' Is <br /> SITE ADDRESS <br /> Nurawr ,� PIN Cy 5-1`- L--Q?C>1 , CA R S 2-4-!:Dsass N=* Ty" Sudo 0 <br /> Mailing Address (If Different from Site Address) <br /> CITY + <br /> 1-�J STATE � �IP <br /> c �7 I C)I fO�IJ <br /> PHONE#1 fir• APN# LAND USE APPLICATION# <br /> ( ) 2� - <br /> PHONE#2 - BIDS DISTRICT LOCATION CODE <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REQUESTOR n y <br /> BILLING PARTY CI <br /> BUSINESS NAME PHONE# Exr. <br /> MA711NG ADDRESS -j- <br /> �^ <br /> 0, <br /> li�)c L / �^ <br /> ICJ`F� FAX# <br /> Ctrr ' �� - -DC7 ( (o <br /> V STATE C� ZIP c!y)`J 2-4-Ir =D I [CJ <br /> i <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/or,project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges assomted with this project or activity will be billed to me or my business as identified on this form. <br /> I also canify that I have prepared this application and that the work to be performed will be done in acmMance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,SATE and <br /> FEDERAL laws. t <br /> r <br /> APPLICANT SIGNATURE: LATE; <br /> PROPERTY 1 BUSINESS OWNER OPERATOR 1 MANAGER ❑ OTHER AUTHCRIZED AGEt-rr ❑ p � r.1 T� <br /> It APPr r u.T is rot On 9LLKa vm.proof of aud"iZadon to sign hr rsqurrad Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operatorof the property located at the above site address,hereby authoris the release of <br /> any and all results,geotechnical data antilor emriranmemallsite assessment information to the SArr JOAQUIN COUNTY PusuC HEALTH SERVICES ENv1RONMENTAI HEAL-,H ONasiON 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 /> COMMENTS: <br /> SAN Jc,'"," <br /> PUBLIC i . <br /> ElVV1ROIV('AENiG",C H1.arl.lh rivi5i� <br /> INSPECTOR'S SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY: -YPLAYw r7 ( DATE: <br /> 2� 1.2 O - <br /> ASSIGNED TO: t,3 V4, Af_i7 -#�` EmpLOYEE#: r C� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: C q P f E: <br /> Fee Amount: Amount Paid <br /> Payment Date �� / / 1 b�, <br /> Payment Type invoice# Check# Received By: <br />