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1 • I <br /> SERVICE REQUEST EH0061SR revised 07/10/98 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWN?R/OPERATOR // BILLING PARTY❑ <br /> �A`/ e e <br /> FACILITY NAME <br /> SITEADDRESS <br /> Street Number Direction Street Name Type T Suite# <br /> Mailing Address (If Different from Site Address) <br /> a o N, 64 pfd <br /> CITY STATE ZIP p <br /> PHONE#1 EXT. APN#OO 7, /sO _ LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> i <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> BUSINESS NAME PHONE# EXT. <br /> MAILING ADDRESS FAX# <br /> I <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site <br /> and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated With this project Or activity will be billed to <br /> me or my business as identified on this form. <br /> I also certify that I have prepared this application and that a work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br /> Ordinance Codes, Standards, SATE and FED RAL laws. <br /> APPLICANT SIGNATURE: X DATER <br /> PP,CPERTY/BUSINESS OWNER OPERATOR/-MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY.Proof of authorization to Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, I, the owner or operator of the property located at the above site address. <br /> hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNrr <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <�;1 �-( <br /> COMMENTS ❑ SPECIAL CONDITIONS)OF APPROVAL❑ OTHER ❑ <br /> P I <br /> r <br /> FEB 91999 --- <br /> SAN JOAQUIN COUNrr <br /> PUBLIC HEALTH SERVICES <br /> I <br /> INSPECTOR'S SIGNA �/ j CONTRACTOR'S SIGNATURE: DATE: <br /> APPROVED BY: EMPLOYEE#: 'r � (� DATE: <br /> ASSIGNED TO: G EMPLOYEE#: DATE: k <br /> Date Service Co leted (if already completed): -} <br /> t SERVICE CODE: Z- PIE: O <br /> Fee Amount: ' c� Amount Paid Payment Date Cl '? --�h <br /> Payment Type Invoice# Check# Received By: <br />