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I 0 0SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> nl F d- 13 V-7 <br /> OWNER/ 003 - i C <br /> OWNER/OPERATOR <br /> (� &:s C' BILLING PARTY <br /> FACILITY NAME <br /> SITEADDRESS �j <br /> (/ Ztreet Numbv Wrrction / � SUM Namra <br /> Type Suits! <br /> Mailing Address (If Different from Site Address) D <br /> ✓G�C'W <br /> CITY 4 STATE Zip <br /> PHONE#1 Err. APN# LAND USE APPLICATION# <br /> ( <br /> PHONE#2 _ Exr BOS DISTRICT LOCJ1710N CODE: <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR <br /> BL UNG PARTY❑ <br /> BUSINESS (� PHONE# Ext. <br /> MAILING ADDRESS W — �� — Com/ FAX# <br /> CITY STATE zip ( - (r <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same,acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to me or my business as identified on thls form. <br /> I also certity that 1 have prepa this appli ionan that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance es,Standards,STATE and <br /> FEDERAL laws. / <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> Il APP.c wr is not rhe BiLLM Pnmy Proof of aulhorization to sign Is requi Title <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,geotechnical data and/or environmentallsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERvrCEs ENVIRONMENTAL HEALTH DIVISION 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: V ( 'i <br /> COMMENTS: PA GE�v E.D <br /> ,JUN 5 2N3 <br /> SP <br /> BLIc aPm COON" <br /> o SRV CES <br /> ' ENVIRONMENIA�HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. L EMPLOYEE#: ZZ DATE: C <br /> ASSIGNED TO: J s <br /> EMPLOYEE#: Q DATE: <br /> Date Service Completed (if already completed . SERVICE CODE: <br /> �q00 ;, •PIE: <br /> Fee Amount: <br /> Amount Paid ,. Payment Date <br /> Payment Type Invoice#• Check# ` <br /> t{1 t f Received By: ��� <br />