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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER 1 OPERATOR /� BILLING PARTY 0 <br /> rQc.�li� �r"u t�xs•�� l._U <br /> FACILITY NAME co <br /> SITE ADDRESS <br /> 61 :)O S'.M.'. 1 0 - Sb*la Nam. Type sate r <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 Exm: BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY Sc <br /> C,.0 f e <br /> BUSINESS NAME PHONE# Exr <br /> 0bvAw 1 6(-)) l S- <br /> MAILING ADDRESS FAX# <br /> Ctrl '2 V*Y'\ rc� TATE Z)v S <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner,operator or authorized agent of same,adamowledge that ad site and/or project specific <br /> Pusuc HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or aCNily will be billed to me or my business as identified on this form. <br /> 1 also certify that I h eprep2redth' ;p:p�r�ica !nd that the 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: \CII 2 �ti`1 <br /> PROPERTY/BUSINESS OWNER OPERATOR I MANAGER 0 OTHER AUTHORIZED AGENT 14 <br /> BAPFLr-4NTiS 1W 0X 8wrePAary pv&af audwiatlon to sign is required rifle <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property located at the above site address,h adtAdtmali diai4i4se of <br /> any and all results,geotechnical data andlor environmentaftte assessment information to the SAN JOAQuW COUNTY PUKX HEALTH SERVICES ENVIRONMENT��I� " <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 /> ��L•I' <br /> AN JCA *N COUN it <br /> ?U ! C f tE TH SCE <br /> MMENTS ERVICIRO ke� N <br /> r, <br /> O•! \r� `p_��-5 7�`�,n17<'� �jn 0 �•,�� C_t v��r� Co _o� <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: I en E�tPt iF. DATE: L, <br /> ASSIGNED= EMPLOYEE# DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E:. � <br /> Fee Amount: �- Amount Paid Payment Date a. <br /> Payment Type Invoice# Checit# Received By: <br /> o rP hLA ,-- <br />