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f SERVICE REQUEST 4 M <br /> Type of Business or Property <br /> I FACILITY!D# SERVICE REQUEST# <br /> OWN f PERATOR _ 7 <br /> ?CZ <br /> GLL BIWNG PARTY lJ <br /> FA N i <br /> SrfEAoORESS�f <br /> 1 $treftNumbfr Direcqun <br /> Mailing Address (!f Differ nt from Site Address) a>mf <br /> C <br /> STATE ZIP <br /> PHONE#4 Exr. APN# <br /> LAND USE APPLICATION# <br /> PHOHE#2 BOS DIST= <br /> I-OCATIOH CODE <br /> • - I . <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> BtWNG PARTY Cl <br /> BU [NESS NAME <br /> I <br /> PHON # <br /> nil i�jpD E S�_- 1=Ax# <br /> STATE <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all✓site andler project spedfic <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISIDN hourly charges 2S50dated with Ihis projector activitywill be billed to me or my business as identified on Ihls 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 JOAO=COUNTY Ordinance Codes,Slandands,STATE and <br /> FEDERAL laws. <br /> APPUCANTSIGNATUR <br /> DATE: C E <br /> 3 ori <br /> PROPERTY I BUSINESS OWNER Q OPERATOR/MWGER d OTHER AUTHORIZED AGENT Q-pr_o fa _Q,( aaaf- <br /> IYAPPur�ris not fhe Qum proof otaufhorizaflon to sip is rvaukvd Titre <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.1,the owner or operator of 1110 property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentalfsile assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SER=cs ENVIRONMENTAL HEALTH DMSION as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> - I <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: i"s <br /> I <br /> I <br /> I <br /> i <br /> I <br /> INSPECTOR'S St NA RE: CONTRACTOR'S SIGNATURE: <br /> APPROVED 4Y:. EMPLOYEE#: <br /> DnrE: -oo <br /> ASSIGNED TO: EMPLOYEE 4: DATE: — I <br /> .Date Service Co Ictcd (it already compcted): ';Y"" SERVICE CODE: <br /> Fee Amount: <br /> Amo nt aid `7 Payment Date <br /> Payment Type Invoice#' Check# Received By: <br /> I <br /> I <br />