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SERVICE REQUEST FACILITY ID# SERVICE REQUEST# operty Type of Business or Pr BILLING PARTY OWNEV OPERATOR FACILITY NAME C 1� C v SREADORESS642 j $teetNumber Direction 111 Street Ny^e Type Suite i Mailing Address (If Different from Site Address) L ^ p STATE ZIP CITY LANDUSEAPPLICATION# PHONE#1 aT• APN# `?� BOB DISTRICT LOCATION CODE PHONE#2 CON SERVICE REQUESTOR BILLING PARTY❑ REQUESTOR PHONE# Err. BUSINESS NAME _f �' c 7�rc _ .�3 c . FAx# /U MAILING ADDRESS G 7 J STATE C?3 ! ZIP Crnr -C�,L j BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project specific PueuC HEALTH SERVICES E.NVIRGNMENTAL HEPLTH DNISION hourly charges associated with this prosect or actrvrly vnll be billed t0 me or my business as identified on this f°rm• I also certify that I have prepared this appficabon and that the w°rk to be performed wiA be done in accordance with as SAN JOAOUIN COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. DATE• APPLICANT SIGNATURE: _ OTHER AUTHORIZED AGENT PROPERTY/BUSINESS OWNER �Y OP OR/MANAGERrive APa�cwr is not the 8 i�Pr-f of wthara2b0n to sign is required 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 any and all results,geotechnical data and/or envlrOnmentallsite assessment information to the SAN JQAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as 500n as it is available and at the same time it is provided to me or rry representative. TYPE OF SERVICE REQUESTED: COMMENTS: ENVIRUNaJ1 cN�h CES H PERMI�I�ER JI CONTRACTOR'S SIGNATURE: INSPECTOR'S SIGNATURE: DATE EMPLO:�r'I'. APPROVED BY: EMPLOYEE#: DATE: ASSIGNED TO: P I E: SERVICE CODE - , Date Service Completed (if already completed): Amount Paid Payment Date Fee Amount: - Received By: Payment Type Invoice# ChecR#