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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ <br /> (J} BILLING PARTY 0 <br /> 313 <br /> � I <br /> FAcILRY NAME <br /> SITE ADDRESS <br /> StraaNum6ar Ol"an LF" Street name <br /> Mailing Address (If Different from Site Address) r Suite <br /> 0 <br /> 1 7UG <br /> CITY STATE zip <br /> � r c <br /> PHONE#1 APN# LAND USE APPUCATION# <br /> PHONE#2r z� Exr. BOS:DISTRICT LOCATION CODE <br /> �- J <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> BILLING PARTY l " <br /> C=cze k' <br /> BUSINESS NAME PHONE# EZT. <br /> MAILING ADDRESS ,r T FAXIt <br /> # <br /> CITY —� <br /> STAT ZIP <br /> BILLING ACKNOWLEDG ENT: I, the undersigned property or business owner,operator or authorized agent of same,acknowledge Oiat all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DrnsloN hourly charges associated with this project or activity will be billed to mo 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 aocordance with all SAN JOAQUIN COUNTY Ordinance �c Ylabdards,STATE and <br /> +� FEDERAL laws. <br /> %PUCANT SIGNATURE:, DATE: CCC <br /> G i <br /> PROPERTY/BUSINESS OWNER A OPERATOR/MANAGER ❑ OT14ER AUTHORIZED AGENT 0 t <br /> if Avm,cmr is not fho Uu rrc P wrY proof of authorinuon to sign Is requfrvd '3 a, <br /> Pus! atfa <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site addHt&,'idreby authorize the release of <br /> any and all results,geotechnical data and/or environmentalfsile 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 /> Q S TrOA C:C� 5o 1 �—�C? Gc !���L� S 1 L.\ <br /> INSPECTOR'S SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED DY:. EMPLOYEE#: r <br /> C�j DATE: <br /> ASSIGNED T0: EMPLOYEE#: 0—7 DATE: <br /> Date Service Completed (if already completed): i U/ I SERwcE CODE: <br /> t _ f PIE: <br /> `7— <br /> Fee Amount: °� Amount Paid - 3 <br /> Payment Date <br /> Payment Type Invoice#' <br /> r Check# Received By: <br /> l � 10i <br />