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SERVICE REQUEST <br /> FACILITY ID# SERVI REQ EST# <br /> PFA <br /> or ProRerty e7`V:V� 7� <br /> BILUNG PARTY <br /> R <br /> Ll <br /> n <br /> SITE ADDRESS I }� � Suits' <br /> tStr.W.Num4r Direction <br /> Mailing Address (If Different from Site Address) <br /> STATE_ ZIP <br /> CITY L 'AL1\ <br /> 1 ort. APN# LAND USE APPLICATION# <br /> PHONE#1 <br /> (a ! BOS DISTRICT LOCATION CODE <br /> PHONE#Z EXT. <br /> CONTRACTORI SERVICE RFQUESTOR <br /> BILLING PARTY❑ <br /> REQUESTOR <br /> Yin, I <br /> PHONE# p ' <br /> i <br /> S ESS NAME ��� �C/ /& <br /> FAX# n �7 <br /> MAIUNG ADDRESS t �� G C/ f / a �p <br /> �CITY STATE G zip �S D 3 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge That all Site and/or project Erecta <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH ers Sn N hourly charges associated with this projector ac vity will be billed t0 me or my business as identified on this form. <br /> nce with ad SAN JCAQUIN COUNTY Ordinance Codes,Standards.STATE and <br /> I also certify that I have prepared this appcation an at the work to be performed will be done in accorda <br /> li <br /> FEDERAL laws. <br /> DATE: <br /> APPLICANT SIGNATURE:, j/9r C? c <br /> PROPERTY/BUSWESS OWNER C3 OPERATOR/MANAGER Cl OTHERTHO <br /> AURZEDAGENT Title <br /> IAPPLCANru not&*B Pt; proof of a"dxy=don to sign a rvqu°vd <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property <br /> located at he above site address,hereby authorize the release of <br /> any and ad rEsuYtS.geotechnical data and/or envlronmentallsrte assessment Information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DMSION as SCC <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> 'r CONTRACTOR'S SIGNATURE: <br /> INSPECTORS SIGNATURE: <br /> APPROVED BY: Z Z.� <br /> �— <br /> EmPLOYEE#: DATE: <br /> ASSIGNED T0: <br /> Date Service Completed ('if already completed): <br /> SERVICE CODE: - 'P!E: <br /> 2 Amount Paid Payment Date <br /> Fee Amount <br /> Payment Type Received By: <br /> Invoice# Check# <br />