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ti <br /> SERVICE REQUEST EH0061SR revised 09/04/98 <br /> Type of Business or Property FACILITY 10# SERVICE REQUEST <br /> OWNEY I QPERATpR .'_ r _ BILLING PARTY❑ <br /> FACT NAME <br /> CLQ' EiV ,V,/ � ✓ <br /> SITE ADDRESS <br /> cCa�/' otrecden Shat!Now Type suite 0 <br /> C-Y.r,'U street Number <br /> Mailing Address (If Different from Site Address) <br /> STATE <br /> �.� <br /> clrr�� �,-` <br /> PHONE#1 ` Exr. APNi� : '- Cf LANG USE APPLICATION# <br /> LOCATION CODE <br /> PHONE#2 err. BOS DISTRICT <br /> CONTRACTOR t SERVICE REQUESTOR <br /> J BILLING PARTY <br /> REQUESTQR /'� %Gam' \ J�JJ Js�Jc= , J��>i.?/3Gy <br /> PHO E# <br /> BUSINESS NAME )1 Z t ��[U .I" "sJ) <br /> ADDRESS, ,,� t� '' 1✓ �d-.7." 51d/ 7,2S !/ FAX* <br /> STATE <br /> clrY ` 'C.I J`� C' ` <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner,operator or authorized agent of same,,acknowledge that all site <br /> and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to <br /> me or my business as idenf on this form. <br /> I also certify that I have p parer this app/tcation a that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br /> Ordinance Codes,Standa ,STA and F ,EEL <br /> APPLICANT SIGNATURE: , /' DATE• <br /> TOR/MANAGER ❑ ' OPIERAtt"MEDAGENT <�r ` 6 <br /> PROPERTY/BUSINESS OWNER ® Titre <br /> ►fAPPLlCJNT is►►ot the 131t�+�PARTY.proof ofa to sign a .. <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 environmentaUsite assessment information to the SAN JOAQUIN COUNTY <br /> PUBUC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same fim it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: D'�� iy J�)!G/,/� ✓_�7 j�l J'� Q <br /> COMMENTS❑ ` SPECIAL COWWN(S)OF APPROVAL❑ `-_ OTM/ <br /> ! PAYMENT <br /> SEP 1lqqA <br /> SAN JOAQUIN CUL, <br /> ENVIRONMENTAL HEALTH DIVISION <br /> CONTRACTOR'S SIGNATURE: DATE: <br /> INSPECTOR'S SIGNATURE: <br /> C EMPLOYEE#: DATE: q <br /> APPROVED BY: p p <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> SERVICE CODE: 05 5 4— P i E: <br /> Date Service Completed (if already completed): Zgt}- <br /> Fee Amount: C, <br /> Amount Paid Payment Date <br /> Payment Type Invoice Check# Raccived By <br />