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SERVICE REQUEST <br /> Type of Business or Property <br /> FACILITY IDK SERVICE REQUEST# <br /> BILUNG PAR,f <br /> 10WER I OPERATOR <br /> F A <br /> SITE ADDRESS I j� Typo Suite <br /> SbImNumbr Dirnton / , Stre�tNarm <br /> Mailing Address (If Different from Site Address) }} <br /> Ctrr STATE ZIP15 vt� <br /> PHONE#1 �• APN# LAND USE APPLICATION# <br /> (-R y�s - 4 3 6a <br /> err. BOS DISTRICT LOCATION CODE <br /> PHONE#Z <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> BIwNG PARTY C; <br /> REQUESTOR <br /> PHONE# Err. <br /> BUS ESS NAME chi (oC (o ��d 0 <br /> 0- <br /> uHG ADDRESS t FAX# <br /> MAI <br /> _ q( 1, Y�- AV P j <br /> Cm' STATE Ya ZAP 9S S'3 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or projectspedilc <br /> PUBLIC HEALTH SERVICES ENvIRGNMENTAL HEALTH DIvisION hourly charges associated with this project or acedy will be billed to me or my business as identified on this`con. <br /> I also certify that I have prepared this application an -that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. Lc.�G,y <br /> APPLICANT SIGNATURE:. <br /> DATE: ,l <br /> PROPERTY/BUSINESS OWNER Cl OPERATOR/MANAGER ❑ Crn+ER AUiHCRQED AGENT Title <br /> If APPr c wr is not the BBQ P-oof of authora2don to sign rs required <br /> AUTHORIZATION TO RELEASE INFORMATION: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,geotechnicat data and/or environmental/site assessment information to the Sew JoAQUw COUNTY PuBUC HEALTH SERVICES E vIRONMENTAL HEALTH DMSIoN as soon <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 /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EuPLCYEE if: DATE• <br /> ASSIGNED T0: <br /> tEim;PLOYEE M. DATE: <br /> Date Service Completed (if already completed): <br /> SERVICE CODE: P/E:. <br /> Fee Amount I Amount Paid Payment Date <br /> Payment Type <br /> Invoice# Check# Received By: <br />