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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0 a 3 a SgS" <br /> OWNER I OPERATOR BILLING PARTY❑ <br /> FACILITY NAME '^ v/ e- <br /> SITEADDRESS �-t F �J A —r-v� > /e��o <br /> z�I� Saner Numbv 0ircction f ( StreK Name Typ. Suite: <br /> Mailing Address (If Different from Site Address) <br /> `JA.R-t <br /> CITY STAT��,, ZIP <br /> L)--A� <br /> PHONE#1 W APN# LAND USE APPLICATION# <br /> M/1') &a4- y� 02-1- ado- A - oz-l�� <br /> PHONE#2T• BOS DISTRICT .: LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY' <br /> BUSINESS NAME PHONE# T <br /> 3 —CeG/3 <br /> MAILING ADDRESS FAx# <br /> CITY T> C14�- Q Z1P <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project spedfic <br /> Puauc HEALTH SERVICES ENVIRONMENTAL HEALTH DIvIsIoN hourly charges 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 repared this appfication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY I BUSINESS ❑ OPERATOR./NWIAGER ❑ OTHER AuwRao AGENT /'GLJ.c1l3YI <br /> If APR-r-w is not Oa Btlyrc Pam proof of aurhoriation to sign is rWuiiadl 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 envimnmental/site assessment information to the SAN JOAQUIN COUNTY PueuC HEALTH SERVICES ENVIRONMENTAL HEALTH OmStON as soon <br /> as it is available and at the same 6me it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: r <br /> SJ`t \ �trysi G1�i'e <br /> COMMENTS: <br /> 4 ll <br /> GO �01F g��N <br /> Y (Q C <br /> INSPECTOR'S SIGNATURE: rCONTRACTOR'S SIGNATURE: <br /> APPROVED BY: �/ C� ��.Q� U.PLCYEE#- + S Z Z DATE: —Z� —0 Z <br /> ASSIGNEDTO: Ra` p 3 EMPLOYEE#: � !� DATE: '-Z3 0 Z <br /> Date Service Completed (if already completed): SERVICECOOE ��• 2 2 P!E:. 2 <br /> Fee Amount: •? Amount Paid -7 a r Payment Date <br /> Payment Type �/ Invoice 9 Check it C D Received By:Z�_ <br />