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16 SERVICE REQUEST Funnaico. <br />Type of Business or Property <br />BUSINESS NAME <br />E-07 <br />FACILITY ID # <br />MAILING ADORE'1 <br />12S 1 r <br />SERVICE REQUE T # <br />2WNg1 OPERATOR <br />Net njbg1 <br />CS' <br />BILLING PARTY <br />FACILITY NAME b ^ <br />SITE ADDRESS �Rzo 3 <br />N <br />Gases W / 2—O <br />Street Number <br />Directon <br />/ S"o Nme <br />Type <br />SuiteO <br />Mailing Address (If Different from Site Address) <br />-QDK(nEs <br />;2, <br />CITY yZ cr 1 _ C! l - <br />ffNA' JTQ IG'r"O <br />V"r n ^ <br />STATE ZIP q S � (o <br />PHON #1 <br />Za <br />ASSIGNEDTO: L <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 En. <br />BOS DISTRICT <br />Date Service Completed (if already completed): <br />LOCATION CODE <br />CONTRACTOR I SERVICE REQUESTOR <br />REQUESTOR j <br />BILLING PARTY ❑ <br />BUSINESS NAME <br />E-07 <br />PHONE # EXT. <br />MAILING ADORE'1 <br />12S 1 r <br />FAX# <br />CITY (V „ _ <br />I _ S- f _ STATE ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site <br />and/Or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project Or activity will be billed t0 <br />me or my business as identified on this form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br />Ordinance Codes, Standards, STATE.and FEDERA � <br />APPLICANT SIGNATURE: l J L� DATE: L/, A 1 <br />PROPERTY/BUSINESS OWNER ❑ OPERATORI MANUR ❑ OTHER AUTHORIZED AGENT ❑ W !"'� <br />IfAPPLICANTis not the BILLINGPARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, <br />hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS ❑ SPECIAL CONDITION(S) OF APPROVAL 11 <br />OTHER <br />❑ <br />INSPECTOR'S SIGNATURE <br />NTAT'N <br />DATE: <br />/Z 2l <br />APPROVED SY: r <br />EMPLOYEE#: <br />LL� <br />DATE: CC..--Z�� <br />ASSIGNEDTO: L <br />EMPLOYEE#: <br />O(',�}' <br />DATE:. <br />Date Service Completed (if already completed): <br />SERVICECODE: D P 1 E: <br />Fee Amount: '7c, �L- <br />Amount Pai <br />70.2- <br />Payment Date <br />Payment Type <br />Invoice 9 <br />Check # <br />Received I <br />