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" • SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property <br /> ,�,GQet.a SGltioo� 13us (� 6 3�i�3 0 <br /> BILLING PARTY <br /> OWNER OPERATOR ` ` 4— <br /> FACILITY NAME 5.a4, <br /> SITE ADDRESS � % <br /> r ! ���✓L+ <br /> Street Number Olrecaan <br /> Street Name Type Suite <br /> Mailing Address (If Different from Site Addre5 <br /> � bo N <br /> STATE ZIP <br /> CITY <br /> PHHOONE#1 APN# LAND USE APPLICATION# <br /> °'eo <br /> PHONE#2T BOS DISTRICT <br /> CONTRACTOR I SERVICE REQUESTOR <br /> BILLING PARTY <br /> REQUESTOR n' � , <br /> PHONE# <br /> BUSINESS ;1 6, <br /> �—`�KN KKKXXX a FAX# <br /> MAILING ADDRESS fe <br /> CITY s�D L / (iLl $TATE C� ZIP <br /> BILLING ACKNOWLEDGEMEN"T�IQthye�undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific <br /> dy WIII be blued l0 me Or my business a5 <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DNISION hoUny Changes associated with this project or actiVidentified on this form. <br /> Codes, <br /> I also cerfify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERALIaWS. <br /> DATE: <br /> APPLICANT SIGNATURE: <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ title <br /> IfAPA"Tia Mtfhe BALNG PARTY proof of authorization to sign is required <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operatorof the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environnwllwVsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL 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 SERVICE REQUESTED: <br /> COMMENTS: <br /> INSPECTOR'S SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY: Et.PLOYEE#: DATE: <br /> ASSIGNEDTO: �r a r y� EMPLOYEE#: 0©p DATE: — <br /> SERVICE CODE: P I E: <br /> Date Service Completed (if alread c pleted): <br /> U <br /> Fee Amount: 7(,a 00Amount Paid Payment Date <br /> Invoice# Check# Received By: <br /> Payment Type Q c/�/ J <br /> 0 0 <br />