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SERVICE REQUEST EH0061SR revised 07/10/98 <br /> Type of Business or Property FACILITY ID# SERVICE REQU <br /> OWNER I OPERATOR 7 <br /> BILLING PARTY,I� � <br /> � FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction T i4treet Name Type Suite 9 � <br /> Mailing Address (If Different from Site Address) <br /> . 'Fz:ox <br /> CITY � ` STATE ZIP O <br /> PHONE#1 ►`- EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> BUSINESS NAME PHONE# EXT. <br /> a Jim ►.� � �o+�kS 6Lolo <br /> MAILING ADDRESS FAX# <br /> &X <br /> CITY G\� STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site <br /> and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly Charges associated with this project or activity will be billed t0 <br /> 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 COUNTY <br /> Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof 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 above site address, <br /> hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS ❑ SPECIAL C NDRION(S)OF APPROVAL❑ OTHER ❑ <br /> IN E 0 'S SIGNA URE' CONTRACTOR'S SIGNATURE: DATE: <br /> APPROVED BY: —`� EMPLOYEE#: DATE: ( r 2– <br /> ASSIGNED <br /> ASSIGNED TO: f, EMPLOYEE#: ( !✓ `_ DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: j PIE:I <br /> E <br /> Feent%�( � Amount Paid � �q� _ Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> rax Cx,�-t- -F►-. (.�w� oo g9a S �- o a q�y� <br />