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+ SERVICE REQUEST <br /> t FACILITY ID i* SERVICE REQUEST <br /> Type of Business or Property (� <br /> T1 % BILLING PARTY ❑ <br /> OWNER I OPERATOR <br /> FACILITY N� <br /> L'` Typo Suite <br /> SITE ADDRESS 11 Name L-1 <br /> �j Street Numo+r mlr�O^ <br /> Mailing Address (If Different from Site address) <br /> > r STATE ZIP <br /> Crrr <br /> Ezc. APN# LAND USE APPLICATION# <br /> /-1( <br /> PHONE$1 O f ? /la �5 QT 2- 1 V 7 � v- <br /> BOS DISTRICT LOCATION CODE <br /> PHONE#Z <br /> CONTRACTOR/SERVICE REQUESTOR <br /> BILLING PAR <br /> REO(IF4,10R �+ IT <br /> V/v — /'t: PHONE 7, T Ezr. <br /> BUSINESS VAME Z_ /� / �E Z <br /> FAX# <br /> h1AWNGADDRESS�� <br /> STAT ZIPS 3 <br /> CYcknow17ES� <br /> or business owner, operator or authorized agent of be billed to me memy us business as dentifiedge that ail sed on this form. specific <br /> BILLING ACKNOWLEDGEMENT: 1.AL HEALTH <br /> TH DIVISION <br /> property project or activity <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION houAy charges associated wi71 this pro) <br /> I also certify that I have prepared IN plication an the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinaance�Codes, Standards,STATE and <br /> F_DERAL laws. <br /> DATE: <br /> APPLICANT SIGNATURE: <br /> ClOPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Title <br /> PROPERTY I BUSINESS OWNER KApp cAmr is no(Un 8skZaP�ry proof of aurhorizadon to sign is roWkvd <br /> AUTHORIZATION TO RELEASE iNFORh1AT1ON: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,geotechnicalRELEASE <br /> Bard INFO ehWi]N taUSite assessment into madon to the SAN JOAQUIN COUNTY Pusuc HE.kLTH SERVICES ENVIRONMENTAL HEAL iH DIVISION as Soon <br /> anolor <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: �/Ql y 7O/`Z7 <br /> P�� V <br /> GE,4Nc�ZFA CL�C�� <br /> COMMENTS: <br /> r! <br /> MAY 28 <br /> `PUBLIC HEAtTl'SFR'JICF:S <br /> _N,,r1�iC1^nAch.e ern 't",!�Ic,ri, <br /> CONTRACTOR'S SIGNATURE: <br /> INSPECTOR'S SIGNATURE: DATE; <br /> ESIPLOYEE#: <br /> APPROVED 0Y: <br /> /�/ DATE: <br /> EMPLOYEE?Jr: C`y <br /> ASSIGNED T0: PIE. <br /> SERVICE CODE: 1 <br /> Date Service Completed (ready completed): f �atO <br /> Amount Paid � payment Date <br /> =ee Amount: l�j(a Received 3y: <br /> Payment Type <br /> invoice 9 Check 4 <br />