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0 <br /> SERVICE REQUEST <br /> Type of Business or Property fACILr Y ID# SERVICE REQUUEEST# <br /> 40 f=',C 1--�- !�-:>R10o aC 5 1 <br /> OWNER I OPERATOR BILLING PARTY 0 <br /> Coi <br /> FACILITY NAME p <br /> ?l�I <br /> SITEADDRESS I –�Co C t✓ 4��/�Q130-Str..t � �1 Roma�r OlrectieaYZ�rtypo Suft� <br /> Mailing Address (If Different from Site Address) t �.v V1 <br /> CEN STATE Zip <br /> PHONE#1 EXT. APN# f�m <br /> PPIJCATiON#-(-')/ - 17 <br /> PHONE#Z Er. BOS:DISTRICT LOCATION CODE. <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REO �R BILLING PARTY O <br /> t J L 1 <br /> BUSINESS NAME PHONE# ExT. <br /> e C v <br /> MAIL—[NG D S FAX# <br /> S V <br /> Crrf STATEr+ zIP 5 7`C) <br /> BILLING ACKNOWLEDGEMENT: 1,the undersigned property of business owner,operator or authorized agent of same,acknowledge that an site and/or project specific - <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this projector activity will be billed tome or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to perforTed w'I be one in accordance with all SAN JOAQUIN COUNTY Ordinanco Codes,Slandards,STATE and <br /> FEDERAL laws. A <br /> APPLICANT SIGNATURE DATE: <br /> PROPERTY!BUSINESS OWNER 11E OR/MANAGER 0 OTHER AVTHoMM AGENT <br /> IIAvPur-wr is not rhe fl3trc PMIY.proal of tulhoriz2don to sign Is rWulrvd Tit t <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 environmentaftle assessment information to the SAN JOAQUtN COUNTY PUBLIC HEALTH SERVICES ErlvutONMENTAL HEALTH DMSION 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: S CQ / <br /> n �JYI <br /> COMMENTS: <br /> PAYM E N <br /> RECEIVED <br /> :IAN JOAQUIN COUNTY <br /> POILIC HEALTH SERVICES <br /> INVIRCNNIFNTAI HEALTH DIVISICN <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED 13Y:. EMPLOYEE#: G f DATE: <br /> 1111 C ?i;7 Q <br /> AssicmEoTO: EMPLOYEE#: & V !f DATE: 77 � <br /> :Date Service Completed (ii alre completed): !f�Z 3 d [ $ERViCE CODE: - S P l E: �G <br /> Fee Amount: -7 Amount Paid ! QO FPaymant Date �/ I <br /> Payment Type invoice#' Check# a� J� Received B : <br />