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SERVICE REQUEST <br /> Type of B sln� r operry FACILITY ID# SERVICE REQUEST# <br /> l�L 3 <br /> OWNEROPERhOR BILLING PARTY 0 <br /> FAcit.r7 NAME <br /> SITEADD7Aa5-?' <br /> , l,„y�, �y , j.—. �svutxvmh.r Okeetian '-f'f f f`' �y SW�t +mN � Type Suk.1 <br /> Mailing Address (If Different from Site Address) <br /> CITY t�E <br /> PHONE#i T• APN# LA►to USE APPLxATi0H# <br /> / 3o ^ o t <br /> PHONE#2 EXT. 05 DtSTRiCT l ocartorr.CooE ...; a`. <br /> CONTRACTOR!SERVICE REQUESTOR I <br /> REQUESTORr� BU MG PARTY 0 <br /> BUSIHS NA�rE owr� ` PHONE# <br /> �S <br /> MAILING ADDRESS FARC# <br /> CITY ! L:✓ 7 STATE ZJP / <br /> C.�^�-/ zY't� <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site andlor project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this projector activity will be billed to me 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 wilt be done in accordance with all SAN JOAQUw COUNTY Ordinanco Codes,Slandaids,STATE and <br /> � Ft:DERAL laws. � . <br /> t APPLICANT SIGRATURE: <br /> __r�'�— DATE. <br /> PROPERTY!BUSINESS OWNER OPERATORI t4 W,GER 1-06— OTHERAmORIZED AGENT <br /> 1f APrrxrwrisnotthedlltaCpnftrx pnao(aftuthoriijllontusiflnisroquirvd Titlo <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby authorize Ude release of <br /> any and all results,geotechnical data andlor envirommentallsite assessment information to the SAN JOAQUIN COUNTY PUBUc HEALni SERviCEs EwRoNMENTAL HEALTH DMGION 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: T <br /> Ub S C <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVED <br /> qU G 2 1 2040 <br /> P&tc SOLI"SERV1GES <br /> ENVtV aON+IEN%HEALTH 41VIStE?N <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> EAPPROVEC)DY:. <br /> EMPLOYEE#: DATE:0: r, () � EMPLOYEE : �� t� DATE: t <br /> .'Date Service Completed (ifalreadyco pleted): SERVICE CODE: PIE. 240 <br /> Fee Amount-, Amount Paid Payment Date ���-7C2) <br /> Payment Type Invoice W Che # a e%e-_7 Received 8y: <br />