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SERVICE REQUEST <br />CU14IKA, IUKIaCMV1%,Cr%ZWWQ 1— <br />REQUESTOR <br />(� <br />�a <br />BILLING PARTY C3 <br />vV PHONE#� <br />BUSINESS NAME <br />MAtUNG ADDREss l Fax # <br />STATE el� �P �� <br />CITY t I <br />��— <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 ENVIRGNMENTA.L HEALTH ONLSIoN hourly charges associated with this projector activity will be billed t0 me or my business as identified on this form <br />I also certify that I haveprepared ' DATE: apprication and that the work to be performed will be done in accordance with all SAN JOAOUIN COUNTY/Ordinance Codes, Standards, STATE and <br />FEDERAL laws. 1 l ( l <br />Z O Z <br />APPUCANrSIGNATURE <br />PROPERTY I BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AtrniORRF,oAGENT Title <br />NAPPLr-Wris not Chet SLUNG p+�cf authoriwdon to skn is rWi vd <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property boated at the above site address, hereby authorize the release of <br />any and aA results, geotechnical data and/or environmentalisite assessment information to the SAN JOAQUIN COUNTY PuBUC 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: ^ t S V 11111 1�4 I � —7 <br />COMMENTS: <br />APPROVED BY: <br />ASSIGNED T0: <br />Date Service Completed (if already completed): <br />Fee Amount: ?k7 <br />Payment Type Invoice 4 <br />EMPLaY= 1t: <br />EmPLOYEE #: <br />Amount Paid <br />Check # <br />PPC vE® <br />S�p.�62p02 <br />SAN <br />30AQ �S RV C S\�� <br />?\O_\ E EPI HEP�jH V <br />ENV\BONN <br />C'EEDATE:7 <br />U <br />SERVICECODE:. �. <br />Payment Date <br />�;LS7 <br />0-7-- <br />'-0d' <br />?7 - <br />-0d' <br />PIE: Z30& <br />Received By: 2�` <br />