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r <br /> SERVICE REQUEST EH0061SR revised 07/10/98 <br /> Type of Business or Property FACILITY ID# SERVICE R ES <br /> OWNER/OPERATOR <br /> BILLING PARTY <br /> FACILITY NAME C <br /> SITEADDRESS aa5o Wes+ <br /> Street Number Direction Street Name Type Suite <br /> Mailing Address (If Different from Site Address) <br /> CITYL O TATE ZIPr Pt <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> _ 3- lo-Ig 1 o +a <br /> PHONE#2 EXT. BOIS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> N O BILLING PARTY❑ <br /> BUSINESS NAME PHONE# !- ExT. <br /> lD — 7 <br /> MAILING ADDRESS FAX# <br /> CITY 1 �, STATE Cp ZIP <br /> T <br /> Lfa 40 <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 t0 <br /> me or my business as identified on this form. <br /> I also certify that I have prep ethis. application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br /> Ordinance Codes, Standards, T�/((TEr FE?ErR*-I 's. <br /> // <br /> APPLICANT SIGNATURE: 11.1 r DATE: ' c- <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 /> 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 COUNTY <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:, <br /> COMMENTS ❑ SPEIL CONDITION(S)OF APPROVAL❑ OTHER ❑ <br /> APR� 6_1499 <br /> SAN JOAC1uIN <br /> �-S TRICEENVIRONMENSli <br /> INSPECTOR'S SIGNATURE: i CONTRACTOR'S SIGNATURE: DATE: <br /> APPROVED BY: EMPLOYEE#: c ' DATE: <br /> ASSIGNED TO: , V v 7 EMPLOYEE#: DATE: <br /> Date Service Completed (11 already completed): SERVICE CODE: �52 2 P/E: 2 3 <br /> Fee Amount: l J �' CQ Amount Paid /5(o.Qd Payment Date <br /> Payment Type Invoice# Check# a, Received By: <br />