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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 9/A <br /> OWNER/ OPERATOR <br /> vve a-a CHECK If BILLING ADDRESS El <br /> FACILITY NAME lJ� i <br /> I <br /> SITE ADDRESS <br /> Se7 Street Number Direction J171�� Street Name Type Suite 9 <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> CITY STATE ZIP gZZD <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR — p <br /> / r 1 c' rn L CHECK If BILLING ADDRESS Low <br /> BUSINESS NAME PH NEEXT' <br /> �'—Z_)l — 1 S <br /> HOME or MAILING ADDRESSFAX# <br /> 5r3�4 l�rZ, a. e� � ( ) <br /> CITY � 1� 15 � STATE V ZIP 5� S <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges <br /> 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 prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDE L laws. <br /> APPLIC.kNT'S SIGNATURE. DATE: 7— ( <br /> PROPERTY/ BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AliTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and <br /> at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: S p j1 ; I 1 I = 'J�:� � <br /> COMMENTS: v <br /> SHiv�uKilUlly'vJJIV I Y <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: / EMPLOYEE#: DATE: <br /> ASSIGNED TO: � d EMPLOYEE#: DATE: /1 4 <br /> t: t <br /> Date Service Completed (if alrea y completed):—/., SERVICE CODE: P I E: <br /> FeAou (S Amount Paid Payment Date it Type l Receipt# —heck# Received By: <br /> SRREQrev.doc 7/1/1999 <br />