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SERVICE REQUEST EH0061SR revised 07/10/98 <br /> Type of Business or Property FACILITY ID# SERVICE R <br /> OWNER I OPERATOR BILLING PARTY❑ <br /> I <br /> � FACILITY NAME � <br /> yo (/tit c V V <br /> SITE ADDRESS pryZ—1` <br /> VjT� (/fit �f{i <br /> V tNumber' Direction �""� et Name pel-' Suited <br /> S <br /> Mailing Address (If Different from Site Address) <br /> I <br /> CITY STATE ZIP <br /> I � <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR G/J �Gr� a)33 y 7�pt BILLING PARTY 1 <br /> BUSINESS NAME �J PHONE# EXT• <br /> o5CMi),7` lY/,9 /C 30— 7 E 7 _ <br /> MAILING ADDRESS FAX# <br /> t✓ (IA/ VC f) fl3 0 <br /> CITY � STATE ZIP� t� 9s'7 ? G <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 PUBLIC HEALTH S RV ES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to <br /> me or my business as identified on this <br /> I also certify that I have prepared plica that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br /> Ordinance Codes, Standards, TE and <br /> APPLICANT SIGN DATE: <br /> PROPERTY I BUSINESS OWNER ❑ Oi eRATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authoriZahon to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, I, 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 environmentaVsite assessment information to the SAN JOAQUIN COUNTY <br /> PUBLIC 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 ❑ SPECIAL CONDITIONS)OFAPPROVAL.rJ❑ OTHER JTJv� - ❑ <br /> AyZCEI 4TE'..) <br /> -- <br /> FED 18 1359 <br /> J. <br /> PUBLIC!IKALTH SERVICE <br /> ✓IHUNM7 NTAL HRnLTH I)IVtFIC- r---- <br /> �..._�� <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: DATE: <br /> APPROVE BY: ( EMPLOYEE#: 0 l DATE: P <br /> ASSIGNED TO: EMPLOYEE#: 0 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: 6 <br /> Fee Amount: Q Amount Paid I(A DU Payment Date <br /> Payment Type ✓ Invoice# Check# Received By: (,j . <br />