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SERVICE REQUEST <br />type of Business or Property <br />— <br />�--- FACILITY ID # <br />r�flr,� <br />�L3S <br />OWNER I OPERATOR <br />os cv 1 • <br />ir; <br />FACILITY NAME <br />SITE ADDRESS AI ti <br />Street Number Direction G �/ <br />Mailing Address of <br />l ` SUaet Nune <br />Different from Site Address) <br />CITY <br />STAT <br />PHONEff <br />Ems <br />APN # <br />LANO <br />PHONE 92 <br />BOS DISTRICT <br />CONTRACTOR I SERVICE REQUESTOR <br />REQUESTOR / <br />BUSINESS NAME \ <br />005Z 1 J etJN S�'i trC f!U c1J <br />MAILING ADDRESS <br />SERVICE REQUEST # <br />BILLING PARTY <br />'rV® $UIO R <br />ZIP <br />USE APPLICATION # <br />LOCATION CODE <br />BILLING PARTY <br />YPHE# EXT.g 543 so s t, <br />CITY ���,�. O iYt:� /�/rJOI't/T F7l c%1/•3 <br />& 7`U7 ✓ STATE IjP v <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 prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and <br />FEDERAL laws. <br />APPLICANT SIGNATURE: <br />DATE: <br />PROPERTY/BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APa .mr is not the &LnMBmUy proof of authorization to sign is mquirad <br />Title <br />UTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 DMSION 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 />i <br />C /<� / <br />COMMENTS: <br />�X/57/N5 j:O/Z_ 6j,p I.,J <br />oP w /- a pis /5 G�f a ,,� �, i/ ��C k& fs <br />1"VC49e <br />RECEIVED <br />DEC 909 <br />INSPECTOR'S SIGNATURE: SAN JOAQUIN COUNTY <br />APPROVED BY:CONTRACTOR'S SIGNATURE: <br />PUBLIC HEALTH SERVICES <br />. ' ' EMPLOYEE DATE: L <br />ASSIGNEDTO: <br />EMPLOYEE #:®( / DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: j Cl C)d PIE: <br />•- <br />Fee Amount: <br />oZ 3 Amount Paid / <br />o? 3 �_ Q D Payment Date <br />Payment Type ✓ Invoice # • Check # <br />Received 8y: � , <br />