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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REA )EST# <br /> OWNER/ OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADD@A$a Lit/ 7 o J� �/� <br /> :Z 5 Wet mb Di — Lr \, -r1 T to# <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> CITY 1�a STATE ZIP <br /> PHONE#1 E'IT- APN# LAND USE AP ]CATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REOUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PNONE# EM' <br /> HOME or MAILING ADDRi S$t/O d'1i6C FAx# ) <br /> CITY S STATE ZIP /b !`2- <br /> BILLING <br /> BILLING ACKNOWLEDGEMENT: 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> .APPLICANT'S SIGNATURE: (t/ �_ DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br /> IfAPPLIGWTis not the BILLING PARTY proof of authorization to sign is required Title <br /> .AUTHORIZATION TO RELEASE INFORMATION: 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 t0 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. <br /> TYPE OF SERVICE REQUESTED: L <br /> COMMENTS: pI-cArTa <br /> MN <br /> AUG 19i9wu-,i <br /> ENVIRONMENT LTH SERVICES <br /> INSPECTOR'S SIGNATURE: <br /> CONTRACTOR'S SIGNATURE: HEALTH DIVISIUN <br /> APPROVED BY: 7 EMPLOYEE#: p/ DATE: <br /> ASSIGNED TO: _1 EMPLOYEE DATE: <br /> Date Service Completed (if already completed): ! SERVICE CODE: PIE: <br /> Fee Amount: t S-00 ' Amount Paid- i5� Payment Date 91 lei Iqq <br /> Payment TypeReceipt# Check # 33� Received By: <br /> SRREQIev.doc 7/1/1999 <br />