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SERVICE REQUEST <br /> Type of Business ar Property FACILITY 10# <br /> SERICE REQUEST# <br /> Or <br /> OWNER l OPERATOR 0 0 <br /> f <br /> rZ � 4S <br /> a5 O�� BILLING PARTY Cl <br /> f FActf f NAME ✓ E LGA <br /> STTEADDREss PO A] <br /> 319mso-.n Hun,e�r Orrectiart V <br /> Str►KN+m� Tray Sully! <br /> Mailing Addre s (If Different from Site Address) <br /> CITY <br /> STATE � Z1P <br /> PHONE#'I ry �, <br /> ( , APN# BLAND UsEAppucATION# } <br /> PHONE 92 Eu. <br /> SOS;pISTR1CT' LocAT10HCDDE . <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REQUESTOR 13U.ING PARTY <br /> O G�-4S Nr-' <br /> r BUSINESS NAME <br /> . /fr PHONE# r �� Ecr. <br /> MAXING ADDRESS /� 1 FAX# O <br /> CITY !�C r/ STATE Z!P <br /> Ll <br /> BILLING ACKNOWLEDGEMENT..1, thheeuundersgned property or business owner,operator or authorized agent of same,acknowledge L`sal all site andlor project specific <br /> PUBLIC HEALTH SmvicEs ENviRDNmENTAL HEALTH DIVISION hourly charges associated with this projector activity will be billed to me or my business as identified on this form. <br /> I also Certify that I have prepared ' ptication and a work to be performed will be done in accordance with all SAN JOAwN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL Laws. <br /> APPLICANT SIGNATURE: DATE: D <br /> PROPERTY I13USINESSOwNER ❑ OPERATOR/MANAGER Q OTHER AUTHORIZED AGENT <br /> IfAPm.cwrisndit r Nrrvpmofofaurhoniatlontosign Isrequ T'itta <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property foaled at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentaVsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERvrCES Ew=igmENTAL HEALTH Dmsi0N as soon <br /> as it Is available and at the same time it is provided to me or my representative. <br /> TYPE OF EWCE REQUESTED: <br /> 142 FA CE S 2FA`E 6W7A eV n/ o o .2� _ /le W <br /> COMMENTS: <br /> i <br /> PAYMEN I <br /> RECEIVED <br /> VEB 12 ZOO" <br /> SAf4 SOAOUIN COVI TS <br /> INSPECTOR'S SIGNATURE: •7 P�:LIC i1EfiLTt':;I:RU��r<' <br /> CONTRACTOR'S SIGNATURE: ,ViKW� FtiTHL NtHi.IH <br /> APPROVED BY:. EMPLOYEE#: DATE: <br /> ASSIGNED T0: EMPLOYEE#: (:j-37 r I)ATE: <br /> Date Service Completed (if already completed): S 10ECODE: `�' p f E; �j 0 <br /> Fee Amount c4 Amount Paid 4 <br /> 7 4�, Payment Date a/!oZ f o <br /> Payment Type Invoice 9' Check# ; to U Received By: <br /> 3a <br /> 4 _. 1 <br />