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SERVICE REQUEST <br /> it <br /> Typr euf Business olpl perry FACILITYSERVICE REQUEST# <br /> CI � I ( U1 <br /> OWNER I OPERATOR BILLING PARTY 0 <br /> FACILITY NAMy yy�� <br /> AD R Ss 1 <br /> t� tr triumow �D(rcifon I Type Suite# <br /> \ I, ai' Address (If Diffe from Site Address) <br /> \ Cm STATE ZIP <br /> PHONE#t ExT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2T_ BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTO BILLING PARTY <br /> BUSINESS PHONE# Exr. <br /> bw <br /> X337 <br /> MAILING ADDRESS FAX# <br /> 211.1. <br /> OR TATE ZU <br /> BILLING CKNOVI EDGEfii 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 I have prepared this application and that a 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: ZI <br /> PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT <br /> 11Arw. Tisnotlhetl u PM proof ofaudwrbadon to sign la required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above she address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentallsite 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: �y -IYII/XI JI �jP^Y&JEpe7.. <br /> #7 a�1I�YIy' <br /> AUG .3 1 <br /> 19968' <br /> ENVI O MENTAL H S H ICES <br /> SIOIV <br /> INSPECTOR'S SIGNATURE' CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: "1 . °:'PLCYEE ff: /c P_ DATE: <br /> ASSIGNEDTO: ���V�rI�/� EMPLOYEE#: 6'CP& DATE: 7 3r �f <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: Z-5, 4,tq <br /> Fee Amount: 2 3 a" Amount Paid 6.2Pal yment Date <br /> Payment Type G Invoice# Check# I Z 2 7 Received By: <br />