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w. SERVICE REQUEST -� <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> z z 5F'7s- <br /> OWNERI OPERATOR <br /> BILLING PARTY❑ <br /> FACILITY NAME <br /> $READDRESS <br /> ZStreet Numbs p e tlon �{ K.({� N � Ty, Sul1.0 <br /> Mailing Address (I(Different from Site Addresst <br /> CITY <br /> b ^ STATE LP <br /> PHONE#1 ` F�*� APN# LAND USE App LICATION# <br /> ( <br /> PHONE#2Ecr. SOS,DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQU OR BIWNG PARTY❑ <br /> ✓;¢ ,� rat a„� 1,9 a <br /> BUSINESS PHONE# rsr. <br /> MAILING ADO ESS FAx# <br /> CITY $TATE IF <br /> BILLING ACKNOWLEDGEMENT: I, the underzgned property or business owner, operator or authorized agent of same, acknowledge that an site andlor project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION howdy Charges associated with this pmjw Or acBvity will be billed to me or my business as Identified on this fomL <br /> I also certify that 1 have prepared;his application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,StandaMs.STATE and <br /> FEDERAL IavvS. <br /> APPLICANT SIGNATUREe'O <br /> DATE: <br /> PROPERTY I BUSINESS OPERATOR/MANAGER ❑ OTIIERAUTHORREDAGENT ❑ <br /> I/AVFu.wris no(rhe 0ni.rvc Puny poo(ol aunc�rixadon ro slpn is required Title <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 environmenta Vsite assessment infomlallon to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DNISIQN as soon <br /> as it is available and at the same lime it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> f'AYMIEN-F <br /> RECEMU ? YIVIE111S <br /> �EIYELr <br /> W2320 MAY 2 �ppQ <br /> SAN JOAQUIN COUNTry <br /> PUBLIC HEALTH SERVICES SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION 'UBUC HEALTH SEf?yICES <br /> -,vvl,TOrdMFNTAL HEALTH' NISIOI.. <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:.. EMPLOYEE#: 39�� DATE: q <br /> ASSIGNEDTO: AA _ EMPLOYEE#: / DATE' i <br /> Date Service Completed (if already completed): - SERVICECODE: / i PIE: <br /> Fee Amoun 15� Amount Paid <br /> Cc) Payment Date 1G 2-5 <br /> Payment Type Invoice#' Check 9 Received By: <br />