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SERVICE REQUEST <br /> T•�1of Bus'r�esj Property FACILITY ID#1 SERVICE REQUEST# <br /> 0 NERJ OPEAAT ' BILLING PARTY <br /> FACILITY NAMET <br /> SITESID-WESS a <br /> ✓✓ i <br /> Street Number , Street Name ��Ti Type Suite a <br /> Mailinress (If DMffen, m Site Adddres?� <br /> C �C'�✓G'< - :STATE <br /> PHONE#1 EXT. APN# LAND USE APPL ICATION# a/ <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> I <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUEST R / �% BILLING PARTY! i <br /> BUSINESS NAME PHONE# EXT. <br /> MAILING ADDRESS 9 FAX# <br /> CITY /� STATE ZIPJr �1 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/Vor'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 epared th�s 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 IawS. 'J , / <br /> APPLICANT SIGNATURE: I1 '�� DATE: 410 <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PAR ry proof of authorization to sign is required 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 PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISiOrI 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: " n <br /> x <br /> COMMENTS: <br /> PACS vED <br /> RE <br /> �OAnvIN S�V CES <br /> HEPI-SHEA�IH DIVISION <br /> P�NMENT A� <br /> ENV1R0 <br /> INSPECTOR'S SIGNATURE: - CONTRACTOR'S SIGNATURE: <br /> nrrnvvED o r; EMPLOYEE#: <br /> ����� I peTE_ z (11 <br /> ASSIGNED TO: O b� EMPLOYEE#: ' DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P i E: <br /> I ee Amount: ��L{ Amount Paid �3 p� Payment Date <br /> Payment Type ��, Invoice# Check# 1.43 Received By: - <br />