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0111N JVA11U11*U1N 1 11_.1N V 11(V1N1VM''1N 1AL KIL AL1GYL'YAK 11VIV1N1 <br /> SERVICE REQUEST <br /> pe of B 'n ss r Property FACILITY ID# U00 <br /> ERVICE REQUEST# <br /> fAoob�► 5� 1 3 / 9 V <br /> OWNER/OPERATOR <br /> y+ CHECK if BILLING ADDRESS <br /> FACRITY NAME / �liJ. <br /> SITE ADD F,�.S 5-street <br /> (_� -fL.LJ r <br /> 16"Street Number Olreotlon ,Street N me I 'AJCode <br /> HOME Or AILING ADD S (If Different from Site Address) /nJ ///� <br /> r IL( tre tNu�ber Street Name <br /> CITY I cJ z7"W� <br /> PHONE <br /> EXT. APN# LAND USE APPLICATION It��/C(/ <br /> 61 ) qq S- <br /> PHONE#2 _rtrt EXT. BOS DISTRICT LOCATION CODE <br /> 22CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR .I CHECK if BILLING ADDRESS <br /> BUST 5 A PHONE# En. <br /> r <br /> HOA19 MAILING ADDRESS FAX If <br /> l-la3 �- <br /> CITY A zip C7 <br /> BILLING AC NOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated 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 IN application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNI•IY Ordinance Codes,Stand d ,STATE and FEDEAAL laws.'n <br /> APPLICANT'S SIGNATURE: 11)-L( Q (Jh V ( / DATE: 1// /65/L0)4J <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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ` �Y 1 GX1 v`� �.t�w-tT (..L �OPOUAN 9Ea�i cEs <br /> hAAL�V SGV CG^jLtL C"�Q B i Vt�Yv1R�l� Ll+� ENN ONME�p11H@p1�H uN1Sb� <br /> a 150 su Ge'll1d l+r''o"S <br /> APPROVED Y:' EMPLOYEE#: t38-1 DATE: I! O Z <br /> ASSIGNEDT (0�'— EMPLOYEE#: Sn b DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: Iq'g PIE: . 'Z <br /> Fee Amount: / Amount Paid ' ( � _ Payment Date t D <br /> 1 <br /> Payment Type ✓ Invoice# Check# a Received By: <br /> EHD 48-01-096 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br /> xv <br />