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SERVICE REQUEST &0� V 9 <br />type of Busin ss or Prope y <br />6--- <br />TOME or MAILING AlypliEqs FAx # <br />10 I () -22 <br />FACILITY ID <br />C7.),, C STATE %'' ZIP <br />SERVICE ROUT # <br />a (� <br />DWN R i OPERATOR <br />HlFeEiVED <br />CHECK if BILLING ADDRESS ❑ <br />:ACILITY NAME <br />AUG 12 linnO <br />iITE AD ESS <br />PUB UIN UOUNTY <br />ENVIRO H LTH SERVICES <br />ov keg <br />a <br />Street Number <br />Direction <br />St <br />et Name ) T e Suite # <br />TOME or MAI ING ADDRESS (If Differe t from it Address) <br />a�✓ <br />�lG. <br />I EMPLOYEE #: <br />:ITY <br />hkAnq,ona <br />1 <br />r <br />ST TE ZIP <br />'HONE #1 <br />ExxT. <br />PN # <br />Date Service Completed (if already Completed): <br />LAND USE APPLICATION # <br />P E. D <br />S "' u <br />Fee Amount: b Amount Paid <br />3�� Payment Date i <br />HONE #Z <br />ExT• <br />Received By: � <br />BOS DISTRICT 1 <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />ZEQUESTOR CHECK If BILLING ADDRESS <br />( h a I vl c <br />_ <br />3USINESS NAME PHOg EXT. <br />TOME or MAILING AlypliEqs FAx # <br />10 I () -22 <br />'ITY <br />C7.),, C STATE %'' ZIP <br />1ILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />cknowledge that all site and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges <br />ssociated with this project or activity will be billed to me or my business as identified on this form. <br />also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />:OUNTY Ordinance Codes, Standards, STATICand FEDERAL lam. <br />kPPLICANT'S SIGNATURE: <br />ROPERTY / BUSINESS OWNER <br />If APPLICANT is not <br />1 DATE: <br />/MANAGER li OTHER AUTHORIZED AGENT <br />ARTY prooof authorization to sign is required Title <br />,UTHORIZATION TO RELEASE INATION: When applicable, I, the owner or operator of the property located at the <br />Dove site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />tformation to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and <br />the same time it is provided to me or my representative. <br />S RREQrev.doc 7/1"1999 <br />E <br />TYPE OF SERVICE REQUESTED: <br />' <br />PAYMENT <br />COMMENTS: <br />HlFeEiVED <br />AUG 12 linnO <br />PUB UIN UOUNTY <br />ENVIRO H LTH SERVICES <br />E L HEALTH DIVISION <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY: <br />I EMPLOYEE #: <br />DATE: <br />ASSIGNED TO:I <br />E.%iPLOYEE #: <br />I DATE: <br />04 <br />Date Service Completed (if already Completed): <br />SERVICE CODE: <br />P E. D <br />Fee Amount: b Amount Paid <br />3�� Payment Date i <br />Payment Type Receipt # <br />Check # Cj <br />Received By: � <br />S RREQrev.doc 7/1"1999 <br />E <br />