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SERVICE REQUEST EH0061SR revised 07/10/98 <br /> Type of Business or <br /> Property FACILITY ID# SERVICE RE EST# Ll <br /> 4tp��-- <br /> I OWNER/OPERATOR <br /> V 6L11 <br /> BILLING PARTY❑ <br /> FACILITY NAME ` <br /> I <br /> SITE ADDRESS F <br /> Street Number D,iirredon Street Name Type Suite# <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE ZIP <br /> 9,573-3 <br /> PHONE#'I EXT, APN# LAND USE APPLICATION# <br /> 323 3,313 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY�I <br /> BUSINESS NAME PHONE# EXT. <br /> I V (Jo 9 <br /> MAILING ADDRESS FAX# <br /> o I - &3 '14A <br /> CITY STATE n_ ZIP 9512 0 <br /> `120 r <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site <br /> and/or project Specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to <br /> me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br /> Ordinance Codes, Standards, STATE and FEDERAL 1 s. <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICANT is not the BILLING PARry,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, <br /> hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as Soon as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: O <br /> COMMENTS ❑ SPECIAL CONDITION(S)OF APPROVAL❑ OTHER ❑ <br /> E <br /> 1 BVIADlaw <br /> i AN JOAQU:N COUN I Y <br /> PUBLIC HEALTH SERVICES <br /> INSPECTOR'S SIGNATURE: I CONTRACTOR'S SIGNATURE: DATE: <br /> APPROVED BY: EMPLOYEE#: I DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P E: GXJ—' <br /> Fee Amount: ,�� <br /> 7? Amount Paid Payment Date <br /> Payment Type r Invoice# Check# Received By: <br />