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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Ol �8 (4:1 o <br /> OWNER/OPERATOR BILLING PART1� <br /> /� <br /> FACILITY NAME --I-. <br /> SITE ADDRESS S <br /> Y,07 5Street Number iron ' / ' — S,.Name Tyye auila# <br /> Mailing Address (If Different from Site Address) <br /> C rr � LO� �TATE ZIP <br /> PHONE#1 T W. APN# LANNDDIUSE APPLICATION# <br /> ( <br /> PHONE#2 Er. BOB DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR �L S-6 le BILLING PARTY 11BUSINESS NAME PHONE# T• <br /> MAILING ADDRESS / FAX# <br /> r V <br /> CITY r a STATE ZIP <br /> I / V <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 DIVISION hourly charges associated with this project or activity will be billed to me or my business as identified on this form. <br /> I also certify that l 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 /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE:_ <br /> PROPERTY/BUSINESS OWNER Cl OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> 1/APPt TiSnoffhe BIWNGP,V? proof of authorization to sign is inquired 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 and/or environmentaUsite 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: D <br /> COMMENTS: D �. I z !,, /� A •��L/`S / <br /> i . <br /> INSPECTOR'S SIGNA RE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: C ESIPLOYEE#: (�fYv / DATE: <br /> ASSIGNED TO: r t EMPLOYEEM D�/ DATE: <br /> Date Service Co pleted (if already completed): SEIrnCECODE: 0 <br /> Fee Amount: 1(-7— Amount Paid if <br /> Payment Date q L 8 9 J <br /> Payment Type Invoice# Check# �a 7 Received By: <br />