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_ SERVICE REQUEST <br /> e of Business or Property FACILITY ID It SERVICE REQUEST# <br /> WNER I OPERATOR BILUNG PARTY O <br /> FACILITY NAME <br /> SITEADDRESS --- <br /> l1 IY/ tr Number oltitc�ooa Name Sults/ <br /> Mailing Address (If Different from Site Address _ <br /> Cm J y� STATE Zip <br /> PHONE 91 APN# C LAND USE APPLICATION# <br /> PHONE#2 OS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESMIA BILLING PARTY❑ <br /> BUSINESS tUvAE � t �\ �0 �V � NONE#i:& <br /> MAILING ADDRESS /�r1 r 5� S 4-e— A FAX# /& 75Y 43/(Q z- <br /> CITY Uvbvb L_ V�1 S STATE !/ Zip <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge Uiat all site and/or project specific <br /> PUBLIC HEALTH SERVICES" NVIRONMENTAL HEALTH DIVISION hourly Charges associated with this project or activity will be billed to me or my business as identified on thL^form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL IawS. <br /> APPLICANT SIGNATURE: �V\�� (\A- DATE: <br /> PROPERTY/BUSINESS OWNER O OPERATOR/MANAGER OTHER AUTHORIZED AGENT Q <br /> l(AvaLrwrisnot fhopivaJGPvrn proof ofauthorizaUontosign isroquirod rifle <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 environmentaUSlte assessment information to the SAI+JOAQUIN COUNTY PUBLIC HEALTTI 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 /> r <br /> TYPE OF SERVICE REQUC'STED: / � ��• �.`/ ' <br /> COMMENTS: / <br /> ECEIVED <br /> - ------��T 1 <br /> - 2001 <br /> INSPECTOR'S SIGNATURE:' CONTRACT A� COUNTY <br /> APPROVED DY:. EMPLOYE'_=#: CEJ 7�L HEALTH i <br /> r 1 TE: <br /> ASSIGNED T0: I Aj h /JQ EMPLOYEE#: <br /> U L/ DATE: <br /> Date Service Completed (if alreakly completed): SERVICE CODE: <br /> '5( S PIE: �3 <br /> Fee Amount: Amount Paid `d Payment Date <br /> Payment Type Invoice#• Check# <br /> Received By: <br />