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SLRVICEREQUEST <br />I ype of business or Property <br />n P <br />FACILITY ID # <br />I <br />SERVICE REQUEST # <br />FA 00016-7 0 <br />��p0�r9fc�C <br />OWNER I OPERATOR <br />g4 h/L <br />BILLING PARTY O <br />FACILITY NAME <br />DI)TYL <br />/, / <br />-7 <br />� � 7©�_J`1 <br />Y <br />SffEADD <br />elL(U^ <br />/ <br />Strat Number <br />Wrection <br />Mailing Address (If Different from Site ddress) <br />�%(,�> <br />l <br />CITY <br />—(*b <br />STATE ZIP <br />PHONE #1 <br />( <br />ExT• <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />Exr. <br />BCS:DISTRICT <br />LOCATION CODE. <br />CONTRACTOR/ SERVICE REQUESTOR <br />BUSINESS <br />PHONE # <br />BURG P <br />EXT. <br />MAILING ADDRESS <br />• Fri Csi1 � � � -� ` FQ # la3S <br />CITYAff STATE + ZIP ?S -A/3 - <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 DrvlsloN 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 a work to be performed will be done in accordance with all SAN JOAouIN COUNTY Ordinance Codes, Standards. STATE and <br />FEDERAL laws. �9 <br />APPUCANT SIGNATURE: DATE: A) oC�e <br />PROPERTY/ BUSINESS OWNER 0 OPERATOR/ MANAGER 0 OTHER AUTHORIZED AGENT <br />IIAPPLCMr is rat rhe BalvG PAmv proof of outhodzadon to sign Is requi 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 environmentaVsite 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: <br />COMMENTS: <br />INSPECTOR'S SIGNATURE: <br />APPROVED BY:. <br />ASSIGNED TO: <br />Date Service Completed (if already completed): <br />Fee Amount: 7 9` 0 <br />Payment Type Invoice # <br />REC vED <br />NOV 6 2003 <br />SAN 30AQUIN <br />ONMENT 14V <br />HEALTH pEPARTMENT <br />CONTRACTORS SIGNATURE: <br />gEMPLOYEE#: ��O-�1 DATE: (�6� ©3 <br />Hj]�� <br />DATE: 1 <br />�1i(-;,p v3 <br />SERVICE CODE: <br />�q, <br />Amount Paid <br />716c Payment Date -7 <br />Check # � 6 Received By: 71/4/ � <br />