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SERVICE REQUEST 46 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OaSr 7 <br /> OWNER I OPERATOR BILLING PARTY <br /> FACILITY NAME <br /> SITE ADDR <br /> �./Street Number Svw Name Suite <br /> ll <br /> Mailing Address (If Different from Site Address) <br /> CITY �� • STATE 'n - ZIP <br /> PHONE#1 - APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#1 ext. BOS;DISTwcT 777r�ocATION.CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR 79 '2 5 j4 BILLING PARTY <br /> BUSINESS NAME ' W , ' PHON # - Ext. <br /> y MAILING ADDRESS FAX# <br /> r CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site andlor project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges 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 COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE' _ DATE:_� <br /> PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT IE.i'�)►Vr P� /tY�r1 <br /> IfAPPt rmr is rat rhe BuyG Prorrv.proof of authorization to sign is requkvd 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 and/or environmentatisite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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 /> COMMENTS: <br /> vwwwn <br /> y .w <br /> DEC 3 019 <br /> 6H114 oOALTUIN Gt)uNTY <br /> PUBLIC HEALTH SERVICES <br /> s <br /> ENVIRONMENTAL.HEALTH I)IVISiON <br /> INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY:. �— EMPLOYEE#: C 00 DATE: <br /> ASSIGNED TO: ,�n <br /> V V`� EMPLOYEE#: �7� DATE: <br /> Date Service Completed (if already completed): SERwcECoDE: <br /> -- PIE: <br /> Fee Amount: au Amount Paid Payment Date I 6 <br /> Payment Type Invoice#' Check# Received By: <br />