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—� �' rS i�e�k �5 G-U[ cI <br /> S.AN OAC*N�COUNTY ENVIRONMENTAL HEA* DEPARTMENT <br /> SERVICE REQUEST <br /> Type Business o Property FACILITY ID# SERVICE REQUEST# <br /> 'Q. Atit7 S SQCb q I QUO <br /> OWNE /OPERATO I _O CHECK If BILLING ADDRESS❑ <br /> FAcnnY NAME O ( 1�L(� <br /> SITE AFI,ORE}S$ <br /> I(.E I IN° <br /> Slreel Number Diredion ree ame� t Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Slreel Number Slreel Name <br /> CITY STATE ZIP <br /> PHONE#1 (,(ll { , fir. APN# LAND USE APPLICATION# <br /> 9 76' <br /> 10 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOft _ CHECK i-E31LI ING ADDRESS <br /> t ir�d���//�/�yl PHONES# EZT. <br /> BUSINESS <br /> Gf fe Al!.iNG!k0^NESS J ne -/\ FAY# <br /> STATE Z1, !;�� <br /> �iiT._P,IG ACCNOWL DCEMENT: I, ib- 2ndersigedreperty ' !;asiness owner, o`n ato "< ;''' <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associat..d with this project or <br /> activity will be billed to me or my business as identified on this form- <br /> I also certify that I have prepared this a 1.cation and Lhat Ow wo!k to be performed will be done in accordance with ali z:AN <.3AGUIr`� <br /> ,)UNTY Ordinance Cotles,StandardslSTIPL and FEDFIrP i laws. <br /> APPLICANT'S SIGNATURE: (� DATE: <br /> PROPERTY/BuSINESSOWNER13 OPERATOR/MANAGER ❑ OTHERAUTHORIZEDAGeNf (� <br /> /f APPLICANT iS not the BILLING PARTY proof of authorization to sign is required <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 environmental/site assessment <br /> infomTalich If the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to m or my representative. <br /> [TYPE OF SERVICE RtOUESTED: <br /> coteaexrs-_� 4 2005 <br /> JON' <br /> H�'fFtDEPP� <br /> PROVED By: <br /> rMPLOYEE#: O ( DAT <br /> ASSIGNED TO: ;vVv_�. -' - EMPLOYEEM �lJ- O DATE• <br /> cg� <br /> Date Service Completed (if already completed): - SERVICE CODE: PIE:-Z`3 G <br /> .lea Amount• m_,. P-";ri $a.'79 D L PAymAn+Date I! p <br /> Payment Type Invoica# Check# �3 Fnceived By: <br /> - EHD 48-01-025 SERVICE REOUEST FORM <br /> REVISED 6-5-02 <br />