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j r SERVICE REQUEST <br />Type of Business or Property <br />BUSINNSS NAME <br />FACILITY ID # <br />MAILING ADDRESSo ' IV r n `� <br />/ <br />SERVICE REQUEST # <br />STATE ' <br />CITY � Cl— <br />"'^ `, <br />EMPLOYEE#: <br />OWNER/ OPERAT It <br />DATE: <br />BILLING PARTY Ll <br />GSc zxku <br />EMPLOYEE#: <br />FACT TY NAME <br />6k <br />/// <br />11 <br />Payment Type <br />SITE ADDRESS 1 <br />4 r <br />�O <br />Received By: <br />Street Number <br />Direction <br />Street Name `� <br />type <br />Suite 6 <br />Mailing Address (If Different from Site Address) <br />CITYK I <br />S+0 G T� yv <br />C HTATE ZIP <br />PHONE #1 Ex"' <br />(aa$ 4 9-31 S3 <br />APN # <br />7 <br />LAND D USE APPLICATION #JT <br />PHONE #2 FXT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR SERVICE REQUESTOR <br />REQUESTORBILLING PARTY <br />' Vn -P� <br />BUSINNSS NAME <br />PHONE #T• <br />MAILING ADDRESSo ' IV r n `� <br />/ <br />F �� JJ & <br />STATE ' <br />CITY � Cl— <br />BILLING ACKNOWLEDGEMENT: I, 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 this torn. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and <br />FEDERAL laws. <br />APPLICANT SIGNATURE: ' DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLING PAR ry proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 environmental/site assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br />as it is available and at the same time it is provided to me or my representative. <br />I TYPE OF SERVICE REQUESTED:�i� <br />n I / %I 7-1COMMENTS: �jr(J J—�I` /T ` (� /`jon <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />"'^ `, <br />EMPLOYEE#: <br />DATE: <br />ASSIGNEDT0: —� J r S <br />EMPLOYEE#: <br />DATE: <br />/// <br />Date Service Completed (if already completed): SERVICE CODE: 0 ( P I E: 43 d <br />Fee Amount: csc� Amount Paid I Payment Date 8� /j- <br />Payment Type <br />Invoice #f� �5� <br />Check # a <br />�/ <br />Received By: <br />41 0 <br />