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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR BILLING PARTY <br /> JAZ�} I � �✓ �� ✓ 1 L C <br /> FACILITY NAME 4;;s <br /> SrrEADD SS C_ S�'/—''/(/I• <br /> A�- Direction <br /> Mailing Address (If Different from Site Address) <br /> / 13 OZO.✓ . <br /> CITY �n ` STATE ZIP O?7 <br /> PHONE#1 (f/O�f'3y—�(�'Sb� OXT. APN# LAND USE APPUcATWN# S <br /> PHONE#2 W. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REOUESTOR BILLING PARTY❑ <br /> J . <br /> BUSINESS NAMEPHONE# Ezr. <br /> c _ <br /> MAILING ADDRESS FAX# <br /> CRY /`XII Al STATE LP <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 DNIsioN hourly charges associated with this project or activity will be billed to me or my business as Identified on this form. <br /> I also certify that I have prepared this application a I t the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERALlaws. <br /> APPLICANTSIGNATU DATE:I/_ 17—�J ,,/,�/'/ <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ /�!VC\ 2Ll_ < _ <br /> IfAPPrcwrisnofft Batu+aPAarv.proarafaudwrizadon to sign isrequtrad Title I <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the properly located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentallslte assessment information to the SNI 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 /> ods f� <br /> COMMENTS: <br /> AtH IVF r—rw <br /> NQV 17 W9 <br /> P BIJC HEq TH SERVICES <br /> ENVIRONMENTAL HFAI.TH ONrgrp,. <br /> INSPECTOR'S SIGNATURE: /I CONTRACTOR'S SIGNATURE: ppp <br /> APPROVED BY:. n / / /J� r/� _ EMPLOYEE#: e� d> DATE: e11117 y/ <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S .P I E:. a,f i `. <br /> Fee Amount: 1-44-) 8 Amount Paid -JB Payment Date 1A I <br /> Payment Type _ Invoice#' Check# Received By: <br />