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SERVICE REQUEST <br />Typ (Busine or Prop rtyACILITY <br />J <br />r' U 2�14 <br />ll J <br />SERVICE REQUEST # <br />Chi' <br />0 ER PE!14TOF <br />BILLING PARTY O <br />FACILITY NAM <br />SITE ADDRESS r, <br />�� Strut Numbtr <br />} <br />Olreceon <br />� amt <br />Type <br />SvRt <br />Mailing Address (If Different from Site Address) <br />Co <br />CRY <br />STATE Zip <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />P OI E#2 r �✓ `G� UT. <br />BOS:DtSTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOi - BILLING PARTY 0 <br />J <br />BUSINESS NAMEI <br />��'t <br />PHONE#T <br />'t <br />MAlL1NG ADDRESS <br />��CA.�(--v) <br />FAX # <br />I. - <br />-( t '� <br />CITY � & ATE ZIP <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 wish this project or activity will be billed to me or my business as identified on this form. <br />I also certify that I have pr pa this application and that t Rork to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and <br />FEDERAL laws. ` <br />APPLICANT SIGNATURE: I �. �\ DATE: <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENTd::)a'U'0Q <br />L 0a <br />ItAvPtr-wr is not the 131 i m Pum proof of authorizatlon to sign Is requfrod Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, i, the owner or operator of the property $orated at the above site address, hereby authorize the release of <br />any and all results, geotechnical data and/or environmental/sile 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 />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />Co <br />rcN���N <br />INSPECTORS SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY:. <br />EMPLOYEE #: t—� j <br />DATE: <br />ASSIGNEDTO: t <br />EMPLOYEE #: � <br />U <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E: Z <br />Fee Amount: `�� Amount Paid `% �2to-7. (D—b Payment Date <br />a ----I� a— <br />PaymentType Invoice # <br />Check # ��:�r <br />Received By: 7r� <br />0-' <br />