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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST R <br /> 0aoas� � <br /> OWNER/OPERATO BILLING PARTY_ <br /> I <br /> FAcI <br /> I <br /> T ^ <br /> SrrE,ADDRESS ) Street Number DlreeNon TYpe swU 1 <br /> Mailing Address (If Different from Site Address) <br /> ST ZIP g52b <br /> PHONE#1 EX'T• APN# LAND USE APPLICATION# <br /> ( <br /> PHONE#2 BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQ9E$TOR BILLING PARTY❑ <br /> Cz� <br /> 5 E -- - — —-- PIG <br /> # 24 Li EXT. <br /> g <br /> ILING D ESS <br /> STATE r ZIP <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 SERVICES ENVIRONMENTAL HEALTH Drvis;oN hourly charges assocated with this pmject or activity will be billed to me or my business as identified on this form. <br /> I also certiy that I have prepared this aoplication and that the work to be performed will be done in accerdance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE ana <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY 1 BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORizEo AGENT ❑ <br /> HAPaIJcAwr is nal the 8aUN6 PAP proof of authorrzaiion to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,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 environmentaVsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HE4,LTH DNISION as soon <br /> as it is available and at the same time it is provided to me or my representative. 1 <br /> TYPE OF SERVICE REQUESIft—i-, L <br /> (���� <br /> COMMENTS: ��lJll l <br /> AUG 1 7 i0 <br /> Sk"'J.JAQIJIN Y <br /> PUBLIC HEALTH SERVIG.=S <br /> En VIRONI'viEN Yat.HEALTH 0;ViS1t?al <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> 4474�APPROVED BY: I EMPLOYEE#: ` DATE: f C <br />.�• I AV SIGNED TO: It XaL &2 � EMPLOYEE r"r: DATE: I <br /> Date Service Completed (if already completed): SERVICE CODE: P f E: v3 <br /> Fee Amount: V Amount Paid Payment Date T <br /> Payment Type Invoice# Check# Received By: <br />