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SERVICE REQUEST x <br /> Type of Business or Property FACILITY ID# SER I(E REQS T# <br /> OWNER/ OPERATOR <br /> L N <br /> a in -k <br /> CHECK if BILG ADORE <br /> M SS <br /> FACILITY NAME <br /> SITE 22 ADDRESS � ( <br /> D Street <br /> t 14-r-'4 11t 0 T". <br /> Suite x <br /> S Street Number Direction <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LANE)USE APPLICATION# G` <br /> PHONE#Z EXT. SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ems'( ) <br /> �tV/L �✓�o <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE ZIP `� S <br /> BILLING ACICNOWLEDGENIENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges <br /> 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 applican ayLnd that the work to performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST a FED-ERA la <br /> APPLICANT'S SIGNATURE: Vc DATE: �—' Z' ��� <br /> PROPERTY/ BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGEN <br /> If APPLICANT is not the BILLING PARTY.proof of authorization to sign is required Title <br /> AliTHORIZATION TO RELEASE INFORINTATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and <br /> at the same time it is provided to me or my representative. // J <br /> TYPE OF SERVICE REQUESTED: CVl2t�J �o�/ t%ir�l dPAYMC"rr <br /> COMMENTS: <br /> AL 21� <br /> SAN JOA0)0N 001!KALIC , <br /> EW QN&tENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EMPLOYEE#: CU l I DATE <br /> t �� 3 <br /> ASSIGNED TO: I EMPLOYEE#: NO 1414 I DATE: <br /> Date Service Completed (I iready Completed): SERVICE CODE: Z P I E: 2/' <br /> Fee Amount: Amount Paid S Payment Date <br /> Payment TypeReceipt# ' Check# Received By: (� i <br /> SRREOrev.doc 7/1/1999 <br />