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w <br /> SERVICE REQUEST <br /> yp of Business rr perry FACILITY ID# SERVICE REQUEST# <br /> 4POVOCD � FSP,00'ac,-4c63 <br /> 0R PE R O&D BILLING PARTY❑ <br /> ((&j <br /> Fac NaME A�t <br /> SrTE ADDRES �� <br /> Strew N —I <br /> er Wre . Type SUN$I <br /> Mailing Ad ss (If Different frdj Si a Addr ssl <br /> 14 A <br /> CrrYnU- S E 22- <br /> PHONE11 APN# LAND USE APPLICATION# <br /> PHO,NE#2 CT• BOS:DISTRICT LOCATION CODE . <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQ[163TCIA V����� BILLING PARTY <br /> BUSINE E .� PHONE <br /> MAIL4G3 s � FAX# el(a0A - - 4 <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersgned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENwRoNMEN HEALTH DmsioN hourly charges associated with this project or activity will be billed to me or my business as identified on this form. <br /> I also certify that 1 have prepared s application and tt aye work to be performed will be done in aocordance with all SAN JOAQUIN COUNTY Ordinanco Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: 2 <br /> PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPc c wr is not the BK Lm Purr!proof of authorizvlon to s/qn Is mqulmd Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.I,the owner or operator of the property k cated at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentailsile assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES EwRoNwNTAL HEALTH DIVISION as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> 5� • I <br /> TYPE OF SERVICE REQUESTED: FAYMENI <br /> RECEIVED <br /> COMMENTS: MAR 13 2M <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY:. „ 1 EMPLOYEE#: DATE: •U \ <br /> ASSIGNEDTO: � EMPLOYEE#: "�2� DATE: <br /> Date Service Completed (if already completed): SERVICECODE: w l� P!E-- <br /> Fee <br /> :Fee Amount: U (i Amount Paid 2� ) 11 Payment Date %j <br /> Payment TypeL Invoice#• Check# �� S� Received By: <br />