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• SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> CODS 2b2 <br /> OWNER I OPERATOR <br /> BILLING PARTY❑ <br /> FACILITY NAME <br /> SITEADDRESS? q <br /> Street Number Olrection D Sheer Name <br /> Mailing Address (If Different from Site Address) <br /> CITY - r� <br /> �C l� STATE zip <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> ( <br /> PHONE#2BOS:DIsTR)cT <br /> LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> //4A06� BILLING PARTY C1� Gf7 <br /> BUSINESS NAME PHONE# , <br /> MAILING ADDRESS 2O <br /> FAx# <br /> CITY �°°,� �G Q y 71 a� 88 - 38 ?O <br /> G I-fJl bf N STATE r_• Z!P 2 2 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge Ulat all site and/or 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 applicatio and that the work to pedo ed will be done in accordance with all SAN JOAQUIN COUNTY Ordinanco Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: Q 2—O / <br /> DATE: U <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑_ �? >T <br /> ifANtrwrisnottho©uMPurry proof ofauthorizadontoslp nis rsqufrwf I <br /> rifto <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 environmentaVsile assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENvutONMCNTAL 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: IA I _ II � � " <br /> 6 ^�- S o l c Wer e— f��-�, 1 e�r!C . <br /> COMMENTS: <br /> PAYMEi __o- <br /> RECEIVF-r <br /> AUG 022007 <br /> SAN JOAQUIN Cc, <br /> PUBLIC HEALTH SE�,„t,; <br /> ENVIRONP,4FNITA <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY:. EMPLOYEE M <br /> G�1'S 7 DATE: <br /> ASSIGNEDdO: EMPLOYEE#: <br /> DATE: <br /> Date Service Completed (if already Completed): <br /> SERVICE CODE: P I E: <br /> Fee Amount: <br /> S 0 6 Amount Paid z! <br /> Payment Date <br /> Payment Type Invoice#' <br /> Check# Received By: <br /> ��I/J <br /> �2 L) 60 tin to <br />