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SERVICE REQUEST <br /> r <br /> Type pfS usNW <br /> ine s or Property ' FACILITY ID# SERVICFR��ESST# <br /> OWN PERA OR CHECK If BILLING ADDRESS <br /> ('21 <br /> FACILITY NA E �e -/7 tog <br /> n <br /> SITE ADDRES C/ a (/�/n„ r C' <br /> 2 treet Number DIf c-tion Lee <br /> Name Type Suite# <br /> HOME or MALNG ADDRESS (If Different from ite Address) <br /> v <br /> CITY STATE ZIP <br /> PH NE 41 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHO # EXT' <br /> HOME or MALING ADD SS FAx <br /> a/-< I o z�;- 1 1 It 'Z- <br /> CITY r STATE ZIP <br /> BILLING ACK�tOWLEDGEyiENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges <br /> 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 the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COLITITY Ordinance Codes,Standards, STATi and FEDERAL law . <br /> nl <br /> APPLICANT'S SIGNATURE: i DATE: <br /> PROPERTY/BUSINESS OWNER OR/MANAGER OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the 'oof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or enviromnental/site assessment <br /> information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and <br /> at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: y It PAYMENT <br /> COMMENTS: C . "E <br /> AUG 12, <br /> RUS P AN JOAQUIN COUNTY <br /> EI VI LIC(HEALTH SERVICES <br /> NMENrAL HEALTH DIVISION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY. EMPLOYEE#: DATE: tZ <br /> ASS+GNED TO; EMPLOYEE#: I DATE: .Z <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: '� Amount Paid 35 Payment Date <br /> Payment Type Receipt# I Check# �q : Received By: <br /> SRREQrev.doc '7M/1999 <br />