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SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# � l t�g (,;;;, 0 OWNER I OPERATOR BILUNG PART1�f� /� FACILITY NAM I SITE ADDRESS ///q/� StreetNumber Zn 4 � street Nang r� whoa Mailing Address (If Different from Site Address) Cern ��o Ci °� GT✓}ATE Z1P _s- PHONE#1 Eu. APN# LAND USE APPLICATION# PHONE#2 ExT BOS DISTRICT LOcATgN CODE. CONTRACTOR I SERVICE REQUESTOR REQUESTOR r BILLING PARTY❑ � x Sfo le BUSINESS NAMEr PHONE# EXT. MAILING ADDRESS ITIV� FAX# CITY L STATE LP 3 7F BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner,operator or authorized agent of same, admdWledge that all site and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly Charges associated with this project of activity will be billed to me or my business as identified on this form. I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAH JOAQUIN COUNTY Ordinance Codes,Standards,STATE and FEDERAL IaWS. APPLICANT SIGNATURE: DATE: PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZE)AGENT ❑ IfAPvtcwrisnotde8s Pwrv.Proof ofmdrarizadon to sign is mWkvd Title 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 any and all results,geotechnical data and/or environmentadsite assessment information to the SAN JOAQUIN COUNTY PUSUC HEALTH SERWCES ENVIRONMENTAL HEALTH DIVISION as soon as r is available and at the same the it is provided to me or my representative. TYPE OF SERVICE REQUESTED:)D0„ . i 'J,,, � ^ ? COMMENTS: 1 � f� ! 313 INSPECTOR'S SIGNA RE: CONTRACTOR'S SIGNATURE: APPROVED 2Y: c j Eur-,CYE-#: V� / DATE: 2 ASSIGNED TO: r t EMPLOYEE#: O� DATE: R Date Service Co pleted (f already completed): SERVICECODE: 03 P1 FeeAmount• i7— Amount Paid ' i7! Payment DatePayment Type Invoice# Check# Received By