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.. a <br />• SERVICE REQUEST <br />Type of Business or Property <br />BUM PARTY ❑ <br />FACILITY ID # <br />SERVICE REQUEST # <br />lzz-"/? to C) <br />OWNER I OPERATOR <br />PAY Nj <br />BILLING PARTY <br />1 Vv 2-Zr t <br />STATE :;A <br />FAcit-rY NAME _ <br />ADR 7 <br />SAN 'OAQUIN CUUN7Y <br />cNVIPUBLJC NMEHEALTH SERNIC'e <br />FITAL <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />SITE ADDRESS <br />AST b S o <br />A1/ i-iV c— <br />DATE: <br />ASSIGNED TO: 60 <br />orrrKtioa <br />f <br />DATE: <br />Ty" <br />sank. it <br />Mailing Address (if Different from Site Address) <br />SERVICECODE:'. <br />P I E:. <br />Clrr <br />Amount Paid <br />��ZIP' <br />CA <br />G <br />Payment Type <br />PHONE#1 EXT• <br />APN# <br />�Zl- � -off <br />LAND USE APPLICATION# <br />CC->< <br />PHONE #2 EXT• <br />SOS DISTRtcT <br />LOCATM CODE': <br />CONTRACTOR/SERVICE REQUESTOR <br />REQUESTOR <br />BUM PARTY ❑ <br />BUSINESS E <br />- C0f)s ULT► <br />P NE# EXT <br />372 f �6 <br />MAIUNG�OR58 <br />G3 S'SVA P <br />PAY Nj <br />FAX # <br />nit37Z:c��� <br />CITY W G , o <br />STATE :;A <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that ad site and/or project specific <br />Pusuc HEALTH SERVICES ENVIRONMENTAL HEALTH DivisloN 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 ' application a that the work do perfo will be done in accordance with at SAN Joaauw COUNTY Ordinance Codes, Standards, STATE and <br />FEDERAL laws. <br />APPLICANT SIGNAT u DATE: <br />PROPERTY/ BUSINESS OWNER Cl OPERATOR I MANAGER Q OnERAuTmoRrzED AGENT �Iw' I T 1 y*w <br />r <br />IfAPPtr wrismarthe8uarcPurrr proolofwtt}artutron 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, hereby authorize the release of <br />any and all results, geotechnical data and/or emrironmentalfsite assessment information to the SAN JOAQUw Coutm PuBUC HEALTH SERVICES ENVIRONMENTAL HEAL-. H DW*N 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:'*k-v� <br />COMMENTS: <br />PAY Nj <br />Wzr' f: <br />ADR 7 <br />SAN 'OAQUIN CUUN7Y <br />cNVIPUBLJC NMEHEALTH SERNIC'e <br />FITAL <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY: <br />E8IPLcy--#. I <br />DATE: <br />ASSIGNED TO: 60 <br />EMPLOYEE#: <br />DATE: <br />Date Service Completed (if alt <br />mpleted): <br />SERVICECODE:'. <br />P I E:. <br />Fee Amount: 00. C)O <br />Amount Paid <br />- <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # - <br />Received <br />I v v — <br />