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SAN JOAQCOUNTY ENVIRONMENTAL HEAV <br /> DEPARTMENT' <br /> SERVICE REQUEST <br /> Type o Business or roperty I <br /> FACILITY ID# SERVICE REQUEST# <br /> (rvuvw—'� ;? L) C-� <br /> OWNER/ OPERATOR �'� f - Ir—�I <br /> CHECK if BILLING ADDRESS IJ <br /> f� <br /> FACILITY NAME <br /> ci4ncLol <br /> PVxbjr <br /> SITE ADDRESS <br /> (/J� /. <br /> Street Number reclion 56re1 Name '! ! Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'1 EXT. APN# LAND USE APPLICATION# <br /> 47) qg("C, <br /> PHONE 42 / y� Ext. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> F2EQUESTOR `-' <br /> CHECK if BILLING ADDRESSE] <br /> BUSINESS NAME 0 i PHON EXd <br /> (at-J, <br /> G n 1 <br /> HOME or MAILING A R SF <br /> (�N� 46 <br /> CITY i �- STATE ZIP <br /> J <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTIt DEPARTMENT hourly charges associated with (his 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TE and l EDE. h s' <br /> APPLICANT'S SIGNATURE: I K <br /> , DATE: <br /> PROPFItTY/BUSINEESS O1VNF.R❑ OPERATOR/I14ANACEIt ❑ OTHFIt AUTHORIZED AGENT (/ /d`7 <br /> If APPLIC`'ANT is not the BILLING PARTY,proof of authorization to sign is required Tole <br /> AUTHORIZATION TO REI,F,ASE INFORMATION: When applicable, 1, the owner or operator of the property located at the <br /> above site address, hereby authorize (lie 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. ik <br /> TYPE OF SERVICE REQUESTED: ECEty {� <br /> COMMENTS: j f S� z rl- INS <br /> U f L t,o <br /> Z o t I b�J SAN S,xxva;M�BAMS; � <br /> I "�ItA�� <br /> APPROVED BY: .1 ----- 7 DATE: <br /> ASSIGNED TO: ('J��h J ���C. �� `t 1� EMPLOYEE#: � l-- .,� DATE: 1i <br /> mp <br /> Date Service Completed (if already completed $CR <br /> : VICE CODE: �Gj' P 1 E: �® <br /> Fee Amount: 3)01- d"U. Amount Paid f Payment Date __ l <br /> Payment Type Invoice # Check# 7ff-1 Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />