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SERVICE REQUEST <br /> Type of Business or Property ,_ FACILITY ID# SERVICE REQUEST# <br /> (/s 11---A DO0G44- 3 S � no3 ! 13 <br /> OWNER/OPERATOR BILLING PARTY <br /> r%L �© <br /> FACILITY NAMEON017 <br /> # <br /> SITE ADDRESS S ,/Str��lNuMbK Olrection / !/� SVM Name <br /> TYPE Sums <br /> Mailing Address (If Different from Site Addressl <br /> CrrY <br /> STATE A2- <br /> LP �� <br /> PHONE#1 EXT. PN# LAND USE APPUCATION# <br /> ( <br /> PHO E ` _ BOS DISTRICT <br /> � LOCATION CODE <br /> J �r <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR <br /> &jk/-Z�� BILLING PARTY 0 <br /> BUSINESS NAME 7;;�,/. PHONE# , <br /> MAILING ADDRESS V U(� U C lam/ F x# Cl/�J LO� / <br /> CITY STATE zip i <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 with this project or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have Sprep ;thisappliiona that the work to be performed will be done in accordance with allSAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER O OTHER AUTHORIZED AGENT <br /> IIAPPLcmr is not ft Uunrcparry pmol olauthoi*ation to sign Its requr �2 <br /> Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmental/site 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: U5T <br /> � 4) t� <br /> COMMENTS: <br /> � 5 2003 <br /> Gov CES <br /> �pUBNME�P HEP SH DIVISION <br /> �NV1R0 <br /> INSPECTOR'S SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY:. EMPLOYEE#: `Z L�( � DATE: <br /> ASSIGNED 70: EMPLOYEE#: DATE:Q' JjG <br /> a <br /> ,Date Service Completed (if already complete ): SERVICE CODE: <br /> PIE:. 3C <br /> Fee Amount: 1 �� <br /> �V '� Amount Paid Payment Date G, 3 <br /> Payment Type Invoice#' Check 9 <br /> Received By: ��, <br />