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SERVICE REQUEST <br />Type of Business or Property <br />BILLING PARTY 0 <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNER PERATOR <br />VIA ((Z- <br />PHONE# EXT. <br />" q6 `f - F� S <br />BILLING PARTY <br />FACILITY NAME <br />FAX # <br />CITY C G _('_ _ <br />RESS <br />SR/J EADt"T O' -Z <br />V — I Streit Number <br />Olrection <br />SMM Nam <br />Type <br />Suh f <br />Mailing Address (If Different from Site Address) <br />INSPECTOR'S SIGNATURE: , <br />CONTRACTORS SIGNATURE: <br />CITY Dom; <br />STATEC ZIPC� ` <br />PHONE #1 <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />DATE: i Q <br />BOS:DISTRICT <br />LOCATION COOE: . <br />CONTRACTOR SERVICE REQUESTOR <br />REQUESTOR <br />BILLING PARTY 0 <br />-� <br />BUSINESS NAME <br />CS -c -S � cc_t� ; > c �,Gi <br />PA YMEly <br />PHONE# EXT. <br />" q6 `f - F� S <br />MAILINGADDRESS <br />b-- 568 <br />FAX # <br />CITY C G _('_ _ <br />STATE c:74 zip Q 7 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge ttiat all site and/or project specific <br />PUDUC HEALTH SERVICES ENVIRONMENTAL EkTH DrnstoN hourly charges associated with this projector activity will be billed tome or my business as identified on this form. <br />I also certify that I ha and that the work to be performed will be done in acoordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and <br />FEDERAL. laws. <br />r <br />APPLICANT <br />DATE: <br />PROPERTY I BUSINESS OWNER 0 OPERATOR/ MANAGER B&�-' OTHER AUTHORIZED AGENT a--ffZb:tcN <br />If Acvucwr is not frta Bate c Pura, proof of mthorinHon to sign Is Mukvd Tit I o 44 r 4 C V1 <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 and/or environmental/Sile assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERv10Es ENVIRONMENTAL HEALTH Drnsw 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 />I <br />COMMENTS: <br />PA YMEly <br />t <br />RECEjIv,`0 <br />. 2rio 1 <br />ZL <br />�� <br />na PUDUC HEcIi NT <br />V <br />H SEOES <br />J <br />INSPECTOR'S SIGNATURE: , <br />CONTRACTORS SIGNATURE: <br />APPROVED BY:. l <br />1 <br />EMPLOYEE #: <br />DATE: <br />v <br />ASSIGNED T0: <br />EMPLOYEE #: <br />DATE: i Q <br />Date Service Complete (if already completed): <br />SERVICECODE: <br />P f E: 4,--'> <� <br />Fee Amount: �-7 <br />Amount Paid Payment Date S'— <br />ti <br />Payment Type Invoice #* <br />Check# <br />Received B <br />MN <br />