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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> 51 � <br /> ' OWNER I OPERATOR BILLING PARTY, <br /> O 5�(1 <br /> FACILrrY NAME <br /> 5trE ADDRESS <br /> Street Humber Direction SIr1HHam� Typo Sung <br /> Mailing Address (If Different from Silo Address) <br /> CTry lq^ STATE zip <br /> PHONE#1 _l� T• APN# LAND USE APPLKATtON# <br /> PHONE 42 cxT: BOS DISTRICT LOCATION CODE <br /> i <br /> i <br /> CONTRACTOR I SERVICE REQUESTOR <br /> i REOIrF.STOR BILLING PARTY❑ <br /> BUSINESS NAME PHONE p Exr. <br /> GO t <br /> j MAILING Armness FAX# <br /> Coq A-OQ <br /> CRY STATE � zip qSa <br /> i <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site andlor project specific t <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DmStON hourly changes 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 COUNTY Ordinance Codes. Standards,STATE and <br /> f FEDERAL laws. <br /> �1/�a/99 <br /> � APPUCANTStGNATURE:�4�,v �4•�� �1 � DATE:—_ _ <br /> 4 <br /> PROPERTY/BUSINESS OWNER Q OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT ❑ <br /> NAP%cwrisrid rhetae MPuarr.prop!ofaurhoriradanfoslpnisrvgohrod Title <br /> AUTHORIZATION TO RELEASE INFORMATION.When applicable.1,the owner or operator of the property located at the above site address,hereby authorize the release of ' <br /> ' any and all results,geolechnical data andlor environmentaUsile assessment Info mabon to the SAM JOAOUIN COUNTY PUSLIG HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at ft same bine it is provided to me or my repnesentam. I <br /> + <br /> FCOMMERTS: <br /> E REQUESTED: <br /> p�Z r1l JZa�•✓� cvvL�/� � GtiGT ` pe <br /> T r$ pw ea pe riarJ r7�A'r � .�=v .^t^7- F0� f5T/Gr! PAYMENT- <br /> s AWA A4 <br /> JUN 1: <br /> SAN JORt:UIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEAITH DIVISION <br /> INSPECTOR'S SIGNATU : CONTRACTOR'S SIGNATURE: <br /> APPROVEDSY: EMPLOYEE#: DATE:IT <br /> ASSIGNED TO: �V— EMPLOYEE 4 DA't:: 111 <br /> r <br /> Date Service Completed (If already co ed): SERVICE CODE: f ! P I E: 3 i; <br /> Fee Amount: C� Amount Paid Payment Date ! <br /> Payment TypeInvoice# Check# Received By; <br /> I <br /> t <br />