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SERVICE REQUEST <br /> EH0061SR revised 09/04/98 <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property <br /> BILLING PARTY❑ <br /> OWNER I OPERATOR <br /> FACILITY NAME��G <br /> SITE ADDRESSSuaea <br /> W" -167 Street Number <br /> Direction Street Narm <br /> Mailing Address (If Different from Site Address) <br /> STATE ZIP <br /> clrY � T�G�c7n�✓ `� �i <br /> PHONE#1E>R. AP N LAND USE APPLICATION# <br /> 170 � a l <br /> BOS DISTRICT LOCATION CODE. <br /> PHONE#2 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> �REQUESTOR BILLING PARTY L 4I�I4L>p STS ' <br /> T� y� '/! ,I PHONE# <br /> BusINESSNAME�E� / L � [/lI/�, / ��C. , 9r -57)- -7-3-S <br /> MAILING ADDRESS �/,/ /9-r- FAX# � Q �_ I7 <br /> CITY <br /> STATE �4 ZIP ' <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same,.acknowledge that all site <br /> and/or project specific Pueuc HEALTH SERVICES ENvIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to <br /> me or my business as identified on this form. <br /> 1 also certify that I have prep red this application and hat the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br /> Ordinance Codes, Standard STAIt<and FE ERAL lavw$ �q <br /> 1' OATS' 7 <br /> APPLICANT SIGNATURE: /I <br /> • OTHER AUTHORIZED AGENT ❑ `��N SN�-��''�`T <br /> PROPERTY IBUSINESS OWNER ❑ OPERATORtMANAGER Title <br /> If APPLlGW is not the 61.UNG ARTY Proof of authorization to sign is required <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, 1, the owner or operator of the property located at the above site address, <br /> hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY <br /> Pueuc HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon 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 /> SPECIAL CONDITION(S)OF APPROVAL❑ OMER ❑ <br /> IS <br /> L 1 V <br /> DATE: <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> EMPLOYEE#: DATE: <br /> APPROVED BY: <br /> EMPLOYEE#: DAT <br /> ASSIGNED T0: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE:E: o't 30 <br /> /9 <br /> Fee Amount: f�7 Amount Paid Payment ate <br /> Payment Type <br /> Invoice# Check# O Z13 411-1 t<' Received BY: <br />