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SERVICE REQUEST <br /> Type of B mess or Pr e// FACILITY ID# SERVICE REQUEST# <br /> OWNER 1 ERATOR BILLING PARTY❑ <br /> il <br /> FACILITY NAME <br /> 7 <br /> SuiteSITE,ADDRESS Number TypaStre # <br /> T <br /> g—Address f Different from Site Address . <br /> 1, / <br /> Ct � / STATE ZIP + ,r,G/6-6� <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> PHONE#2T• BOS DISTRICT LOCATION CODE <br /> product:; <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REC1LffOR BILLING PARTY <br /> I&&L/��' -6rx'10 <br /> Bu ESS NAM PHONE# T• <br /> �. C, 4U i -(c3 3 <br /> MAILING AD RES FAX# <br /> , C�/�07 3 1- /� ); <br /> CITY I jj ., TATE ZIP ,• /�J <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 /> PUBLIC HEALTH SERv:CEs 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 preps e�this 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. r <br /> APPLICANT SIGNATURE: a DATE! <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPucANT is not the BILLMG PARTY.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 andlor environmental/site 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: <br /> PAYMENT <br /> RECEIVED <br /> J U L 17 2000 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: /FI EMPLOYEE: DATE: <br /> ASSIGNED TO: V EMPLOYEE#: DATE: <br /> Date Service Completed (if already co p ted): �. 3 / SERVICE CODE: P/E: <br /> Fee Amount: -J Amount Paid Payment Date <br /> c <br /> Payment Type ���E Invoice# Check# Received By: -04 <br />