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l SERVICE REQUEST 0 <br />T at Business o roe <br />YP i rtY <br />FACILITY ID # <br />RVICE # <br />ribe cJ f�J—ll Q <br />p <br />BUSINESS <br />PHONE # <br />MAILING ADOR <br />OWN41 OPERA? <br />FAX # <br />e <br />BILLING PARTY Cl <br />FACILITY NAME <br />t <br />%/Q'TEA y <br />AUy � "S , <br />8101 <br />SE RESS <br />INSPECTORS SIGNATURE: <br />CONTRACTORS SIGNATURE: <br />APPROVE[) BY:. f <br />EMPLOYEE #:DATE: <br />Strut umbr <br />Dtrecdon <br />EMPLOYEE 9: 3, <br />SWetName <br />�-7 / <br />( <br />TYPO <br />Suk�t <br />Mailing Address (If Different <br />from Site Address <br />P I E: �jp U <br />Fee Amount: <br />Amount Paid 2C� / <br />Payment Date 7 A A <br />Payment Type <br />Invoice #' <br />CITY <br />L <br />Received By: <br />ST <br />� �._zip.-,� <br />PH0NE #1 <br />Ea. <br />APN # <br />d <br />LAND USE APPLICAwN 4 <br />3(o <br />C <br />PHONE #2 <br />exr� <br />BOS:DISTRICT <br />LOCATION CODE: <br />1. <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUEST O <br />t <br />BILLING PARTY, <br />'7 -COMMENTS: <br />p <br />BUSINESS <br />PHONE # <br />MAILING ADOR <br />FAX # <br />e <br />`% <br />CITYzs <br />ATE ZIP <br />BILLING ACKNOWLEDC MENT: 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 E IRONMENTAL HEALTH DnnsloN hourly charges associated with this project or activity will be billed tome or my business as identified on this form. <br />I also certify that I have pr pa this app>tca6on and that th work to be peri ed will be done in accordance with all SAN JOAQUIN C TY Ordinance Codes, Standards, STATE and <br />FEDERAL laws. 16 1. <br />APPLICANT SIGNATURE: DATE: W <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MAN ER ! ❑ OTHER AUTHORIZED AGENT <br />If APRiawr is not the Biu m Purry proof of authorization to sten is requirod T i t t e <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 environmentaUsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENviRONMENTAL HEALTH DNisioN 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: L \ '1 - <br />'7 -COMMENTS: <br />p <br />wz 9 <br />%/Q'TEA y <br />AUy � "S , <br />8101 <br />INSPECTORS SIGNATURE: <br />CONTRACTORS SIGNATURE: <br />APPROVE[) BY:. f <br />EMPLOYEE #:DATE: <br />'� <br />ASSIGNEOTO: <br />EMPLOYEE 9: 3, <br />DATE: <br />�-7 / <br />( <br />Date Service Completed (if already completed): <br />SERvtcECoDE: <br />G <br />P I E: �jp U <br />Fee Amount: <br />Amount Paid 2C� / <br />Payment Date 7 A A <br />Payment Type <br />Invoice #' <br />Check #.� <br />Received By: <br />d <br />