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Type of Business or Property SERVICE REQUEST <br /> FACILITY ID# <br /> SERVICE RE(Q)UEST# <br /> OWNER OPERATOR <br /> rSFTFACnII <br /> BILLING PARTY[IlLm NAMEEAESS ' <br /> eel Numbw Dlrettion L StrM HxnI <br /> Mailing Address (If Different from Site Address) s""' <br /> CITY 1 STATE c� <br /> ZIP <br /> PHONE#1 Ex*. APN# LAND USE APPLICATION# <br /> PHONE#2 FM. BOS DIsTRlcT <br /> LOCATION Cooe <br /> , <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> BILLING PARTY 0 <br /> BUSINESS NAME PHONE# Fes, <br /> MAILING ADDRESS FAX# <br /> G'e'? <br /> ,CITY I STATE zipL <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DmsION hourly Charges associated with this projector activity will be billed tomo or my business as identified on this form. <br /> I also certify that I have prepared this applicatio d at the work to performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> l <br /> PPLICANT SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OVvNER OPERATOR/M WAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> JlAvr ucwris not U a prtLnG Porn proof of juthoriz;tion to sign is roquirod TP /� <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property located at the above site address,hc44IA, sc of <br /> any and all results,geotechnical data and/or enVirOnmcntal/Site assessment information to the SAIL JOAQUIN COUNTY PUBLIC HEALTH Sm- vIccs ENv RONMENTAL <br /> as it is available and at the same time it is provided to me or my representative. soon <br /> TYPE OF SERVICE REQUESTED: 2000 <br /> i COMMENTS: � L 0 <br /> ✓VI RONMfNTE1CH AC?R/ <br /> FICS <br /> DI <br /> It <br /> t s <br /> INSPECTOR'S SIGNATURE: 0tyCONTRACTORS SIGNATURE: —� —Ae <br /> APPROVED BY:. EMPLOYEE#: <br /> � DATE: <br /> ASSIGNED TO: EMPLOYEE 9. DATE: <br /> Date Service Completed (if already completed): Q — «e SERVICE <br /> U / � � PlE: <br /> Fee Amount: ' Amount Paid <br /> t Y 7: QG Payment Date <br /> Payment Type Invoice#' Check# <br /> Received By: <br />