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• SERVICE REQUEST <br /> Ty f Business r Prope I 4FF �FACILITY ID# r SERVICE REQUEST# <br /> 006 JsTt -�4-oo ;�g 37 <br /> OWNt I OPERATO BILLING PARTY❑ <br /> FA r� <br /> ! <br /> 644 A <br /> SITEADDR <br /> Street NAlv.—'Na <br /> umber eceon ,"/"�` ne Type SUN$I <br /> Mailing Address (If Differen om Sit= <br /> LTC1 <br /> CRY fin �" STATE ZIP <br /> PHONE M Err. F <br /> PN# LAND USE APPLICATION# <br /> It i Q319- - <br /> PHONE Er. BOS:DISTRICT LOCATION CODE`. <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUEST / BILLING PARTY <br /> BUSIN S E ,y PH N / <br /> MAILING ADDRESS FAX <br /> C _ ATE ZIP <br /> BILLIN 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 SERVICESFpalthis <br /> MENTAL HEALTH DMSION 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 papplication an t the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinanco Codes,Standards,STATE and <br /> FEDERALlaws. � <br /> APPLICANT SIGNATURE: DATE: / � <br /> 76 <br /> PROPERTY/BUSINESS OWNER 1) OPERATOR/MANAGER ❑ OMER AUTHORIZED AGENT <br /> / <br /> IfApKr-ar is not ft Biu-hy PurTv proof of authorization to sign Is Murrod Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,l•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 environmentallsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DmSION as soon <br /> as it is available and at the same lime it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVE® <br /> DEC � 00� <br /> AN JAQUIN COUNTY <br /> PUBLICOHEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISIUN <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. EMPLOYEE#: O� b' DATE: �. <br /> ASSIGNED TO: EMPLOYEE#: DATE: L/ <br /> Date Service Completed (if already completed): SERVICE CGDE: PIE: <br /> Fee Amount: �6 Amount Paid Payment Date 2'2 I I <br /> Payment Type Invoice# Check# ��� v Received By: - <br />