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0 SERVICE REQUEST 0 <br />Type of Edwiliness or Pro ertt <br />BILLING PARTY <br />FACILITY ID # <br />Re %,MR . T <br />VeD <br /># <br />JAN `,'p 2002 <br />MAILING ADORES r <br />7SE-RVZICEjREQUIEST <br />OWNER/ OP RATOR <br />CITY <br />TATE ZIP e2 <br />S nF� <br />BILLING PARTY ❑ <br />CONTRACTORS SIGNATURE: <br />APPROVED BY:. / <br />EMPLOYEE #: 9!�r 7 <br />FACIurf NAME <br />% <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />S1FrQ�i�iESS <br />SERVICE CODE: <br />T - E: <br />Fee Amount: 7 oD <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice #' <br />meet Number <br />ecdon <br />Received By: <br />Street Name <br />TYPE <br />suHe t <br />Mailing Address (If Different from Site Address) <br />did <br />/ <br />L') <br />d <br />CITYl <br />Srnr ZIP <br />5` <br />PHO%NE, #1 <br />UT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2^�T• <br />—.0 <br />BOS:DISTRICT <br />LOCATION CODE:. <br />I <br />/j CONTRACTOR I SERVICE REQUESTOR <br />REQUESTOR <br />BILLING PARTY <br />BUSINESS NAME <br />Re %,MR . T <br />VeD <br />PHONE # 11T. <br />JAN `,'p 2002 <br />MAILING ADORES r <br />SAN JOAQUIN C <br />FA -X # l <br />CITY <br />TATE ZIP e2 <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 DmstON hourly charges associated with this projector activity will be billed tome or my business as identified on this form. <br />I also certify that I have this application and IhI/,A) <br />ork to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinanco Codes, Standards, STATE and <br />FEDERAL laws. /�j�, JAPPLICANTSIGNATUR ' A VVvv /' DATE: O <br />PROPERTY/BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <br />I/Ava,rwris not the &u xoPurry proof of authorisatfon to sign is requkvd Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property bcated 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 SERVICES ENVIRONMENTAL HEALTH DlvlsroN 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 />r� <br />COMMENTS: <br />Re %,MR . T <br />VeD <br />JAN `,'p 2002 <br />SAN JOAQUIN C <br />NFAi FNVIRBMEN Al TH <br />SEOV E <br />S nF� <br />INSPECTORS SIGNATURE: <br />CONTRACTORS SIGNATURE: <br />APPROVED BY:. / <br />EMPLOYEE #: 9!�r 7 <br />DATE: <br />ASSIGNED TO:— <br />c S <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />T - E: <br />Fee Amount: 7 oD <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice #' <br />Check # <br />Received By: <br />