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L <br />W <br />AL SERVICE REQUEST .40 <br />Type of Business or Property <br />BILLING PARTY ❑ <br />FACILITY ID # <br />SERVICE REQUEST # <br />-� r (c,� E <br />EmpLOYw#: bbCt� <br />Pr ©C b-5y(o0 <br />MAILING ADDRESS <br />(P_ 0, ED A, / C <br />OWNER I OPERATOR <br />FAX # <br />( ) q/6 -3-*; - Its <br />BILLING PARTY <br />STATE C A ZIP 9 S 6 Ct <br />SERVICECoDE: �.�J. <br />P ! E- a3 113 <br />FACILITY NAME <br />r= C o N C c AS <br />Amount Paid !o <br />Payment Date <br />SITE ADDRESS <br />Invoice # <br />t C 'i 0 fL Ar C T <br />Check # <br />Received By: <br />C S. Numbs <br />M.,b.n <br />sbw Nan,. <br />ryv. <br />SuRe x <br />Mailing Address (If Different from Site Address) <br />Clrr O i <br />SC, A <br />ZIP <br />PHONE #1 ET• <br />APN # <br />LAND USE APPLICATION # <br />( -f) Zoe -�b9- oC,S'V <br />PHONE#Z <br />BOS DISTRICT <br />LocAwN CODE.' <br />-S��b <br />_. <br />CONTRACTOR/ SERVICE REQUESTOR <br />REQUESTOR <br />BILLING PARTY ❑ <br />(CWArEL WAf-14 <br />PA YM E IV <br />CONTRACTOR'S SIGNATURE: <br />BUSINESS NAME <br />«t <br />EmpLOYw#: bbCt� <br />PHONE#* <br />�;16 -- 3�3-f�� <br />MAILING ADDRESS <br />(P_ 0, ED A, / C <br />EmpLOYEE #: C� <br />FAX # <br />( ) q/6 -3-*; - Its <br />CITY (AJ .-r �,7 A e— n A 01 <br />STATE C A ZIP 9 S 6 Ct <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 />Pusuc HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project kir activity will be billed to me or my business as identified on this form. <br />also certify that I have prepared this <br />FEDERAL laws. <br />that the work to be performed wril be done in a=rdance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and <br />DATE: I j I S-/ o L— <br />/ BUSINESS OWNER / OPERATOR / MANAGER ❑ OTHER AUTHORQED AGENT ❑ <br />NAPRjcmrisnalthe8 uNcFAarr.proadwitrortradontosignismwkw <br />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 anWor environmentaVSite assessment information to the SAW JOAOUW COUNTY Pusuc HEALTH SERVICES ENVIRONMENTAL HEALTH OMSION 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 />!_.� ., <br />COMMENTS: <br />INSPECTOR'S SIGNATURE: <br />PA YM E IV <br />CONTRACTOR'S SIGNATURE: <br />APPROVEDBY: I <br />EmpLOYw#: bbCt� <br />DATE: <br />ASSIGNED To: <br />EmpLOYEE #: C� <br />DATE: <br />Date Service Completed (if already completed): V <br />SERVICECoDE: �.�J. <br />P ! E- a3 113 <br />Fee Amount:(Z <br />Amount Paid !o <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />112 <br />