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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST R <br /> OwN�RI OPERATOR BILLING PART�:jj <br /> FACIL E <br /> SITE ADDRESS <br /> \ Street Numbr Dir►ctlon Tyo► I Suiu 1 i <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE r� ZIP g52a2 <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> ( <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQ G BILLING PARTY❑ <br /> BU N E # �T• <br /> - - - ON[ <br /> mo <br /> MAILIN ODRE \ ^ ,.,' _ # �. ^ <br /> CITY STATE ZIP LI_ <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 /> PuBL!c HEALTH SERVICES ENVIRONMENTAL HEALTH DnnS,ON hourly charges assocated with this project or activity will be billed to me or my business as identified on this tcmi. <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 Ordirance Codes,Standards,STATE and <br /> FEDERAL laws. Q <br /> APPLICANT SIGNATURE' DATE: v <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANACER OTHER AUTHORIZED AGENT ❑ <br /> MAPPr r wr is not rhe Pura 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 environmental/Site assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENviRONMENTAL HEALTH DNisiON as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICERUE� <br /> COMMENTS: <br /> prym <br /> 'r r,Ei ' <br /> 141 <br /> JHry duHt,tV�:- ,uid I Y <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EMPLOYEE#: � � I DATE: <br /> ASSIGNED TO: /. �`� EMPLOYEE#: v 3 DATE: <br /> FDa Service Completed (if already completed): SERVICE CODE: 730 4 P!E: O34 <br /> Fee Amount: — Amount Paid I Payment Date <br /> Payment Type \/�LInvolce# Check# Received By: <br /> V4064 � � <br />