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1 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# , SERVICE REQUEST# <br /> OWNER I OPERATOR BILLING PART,TL: <br /> /� <br /> FACILITY NAME —L n /� <br /> SITE ADDRESS n - -0 <br /> Strati Number rection �/�/( L(� slreH Nome Ty Suitap <br /> Mailing Address (If Different from Site Address) <br /> CITY V � STATE <br /> PHONE#1 ZIP 5 <br /> / En. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 BOS DISTRICT LOCATION CGDE. <br /> CONTRACTOR I SERVICE REQUESTOR <br /> RBIWNG PARTY❑ <br /> EQUESTOR <br /> le <br /> PHONE# EAT.BUSINESS NAME r <br /> MAILING ADDRESS DI FAX# <br /> / , Ur o6 <br /> G STATE ZIP <br /> Cin' C'r J <br /> BILLING ACKNOWLEDGEMENT: I,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 DNISION hourly Charges associated With this project or activity Will be billed Io 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 Ordinance Codes.Standards,STATE and <br /> FEDERALIaWs. <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHoRRED AGENT ❑ <br /> IfAPPUCANris not the 81UWG Pu+rY proof of authorization to sign is npuired 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 environmentallsite assessment information to the SAN JOAQUIN COUNTY Pueuc 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: a <br /> COMMENTS: �D �„ . i I 3.11 J1 <br /> INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY: EMPLOYEE#: DATE: ((yy <br /> -ASSIGNED TO: r k • e EMPLOYEE#: 0� DATE: <br /> Dale Service Co pleted (if already completed): v SERVICE CODE: 13? PIE: <br /> Fee Amount: 7 Ori Amount Paid Payment Date <br /> Received By: <br /> Payment Type Invoice# Check# �� <br />