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• SERVICE REQUEST <br /> rFActury <br /> pe of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FA 60 is 5 7 <br /> NERI OPERATOR BILUNGP TY <br /> NAMCW C ro ^'�_ �-p � fy,�r77 J ` sT' f fXev e— , `*"1/v'ft dNunOr otrettbn Se N.ma TYPu Sune$ <br /> iling Address (If Different from Site Address) <br /> CITY�J . STATE <br /> SjtrS <br /> PHONE#1 EA• APN# LAND USE APPLICATION# <br /> mcq 33 -8'Yo <br /> PHONE#Z Ext BOS DISTRICT LOCATION CODE' <br /> CONTRACTOR ERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> f/`S <br /> BUSINESS NAME PHONE# Ear. <br /> NG ADDRESS FAX# <br /> _Q <br /> C LP 9"70X <br /> BILLING ACKNOWLEDGEMENT: 1, the undelsgned property or business owner,operator or authorized agent of same,acknowledge that an site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL H LTH NASION hourly dlarges associated with this project or activity will be billed tome or my business as identified on SITS form. <br /> 1 also certify that r have <br /> pre <br /> is app/ don no that the worn to be performed will be done in a=rdance with an SAN JOAQUIN COUNTY Ordinance Codes.Standards,STATE and <br /> FEDERAL laws. / <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHERAUTHORUEDAGENr ❑ <br /> 1(AParriwris raffhe BaurPam.Poofo(authonza k •nia rapuhad Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner eralor of the p party tori at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentallsite assessment inf onto SAN JOAQUIN_C NTY Pu LID H ES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same time his provided to me or my represen ' e. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> arc�Eo <br /> 43 0 <br /> r <br /> 5 Ne G OP HEPPHGE�ION <br /> PO MENS <br /> ENV\FON , <br /> INSPECTOR'S SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY:. .� EMPLOYEE 9: DATE: <br /> -ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICECODE: , PIE: <br /> Fee Amount: mount Paid 1��_ Payment Date 7-31 � <br /> Payment Type Invoice#' Check# of 3 Received By: <br /> it - <br />