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. .��u� .r v+��(u u� �V u hV x Y GN v 1xi V lv rv1x;tV x ill,xx1;Ax+1'll LL:1'A1C1'11'1L;N'1 <br /> SERVICE REQUEST 1 <br /> Type of Business or Property // d .;?S ,7,;pACIGT•Y ID# utl �r•.:SERVICE REQUESTahkif�til ' <br /> 6/2',. <br /> OWNER OPERA R // <br /> e vv rd/t'l + C14ECKIf UjLLINO ADDRESS <br /> FAcko NAME <br /> G �Io % lti ; <br /> I SITE ADDRESS ' <br /> w 40cj� �v�shr� <br /> IRJel Number .. .. .. . . .,. <br /> Street • I -- <br /> HOME Or MAILING ADDRESS (It Dlflere t from Wit) L Address) - ' cob <br /> I L 6 } <br /> / •� Street Number <br /> CITY d O ' TATE ZIP <br /> PRONE#f Ems• APN N LAND USE APPLICATION# �j•� <br /> mid Gz� - 3 4z <br /> (NONE#2 ' �?• :DO��DISTRIGL�+S'"!:'c�h'r.��i+"e iLOCAhI]N'COp�1�Q•' "�; i,(; <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR 'f 1 <br /> j ✓h e1 Cr, I?— �� CHECKIfSILLINOADDRESS0 <br /> BUSINESS NAME PRONE E"T• 1" <br /> �� >~ /mac, / 38 <br /> ( MAILING ADDRESS - - FAX# <br /> e 1:21 o J 3 r0 ) ;'S7- l5'73 <br /> CITY Ce,r 6--c STATE ZIP P6307-1 q10 <br /> UITLING_ACI{NOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same,':` 1 <br /> acknowledge that all site and/or project specific ENviRoNMENrAL HEALTH DEPARTMENT hourly charges associated with tris project or`:y? <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 a work to be performed will be done in accordance with all SAN JOAQUIN , <br /> COUNTY Ordinance Codes,Standards, A and FE laws. <br /> APPLICANT'S SIGNATURE: �J DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ ER AuTnORIZE)AGENT E3 �1 <br /> IfAPPLICANr is not the BILLING PAR ri:proof ojamtkorization to sign is required rifle <br /> AUTHORIZA'PION 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 /> • infb1 nation to tle 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 /> ,✓r- TYPE OF SERVICE REQUESTED:• U5-T- <br /> + NT <br /> Bim% 919 ,' O /Gt-I••el rZ_11 <br /> S •• SANJOA <br /> PUBLIC HEA <br /> QUIN COUN <br /> ' - ENVIRONMfN7tryHA SERVICES n <br /> APPROVED BY; ,.. .. . . .• . .. .. FMPLOYEE#� C C' DATE +, <br /> A / ! <br /> ASSIGNED T0. EMPLOYEE ` DATE' <br /> +' <br /> ( <br /> Date Service Com leted; I(already com Ieted <br /> P . P )• SERVIGECODEp <br /> .e• P1E p <br /> Poe'Amount:;' Amount Paid: <br /> Payment Date Recel4ed,By: <br /> Payment Type Invoice#: v Check# <br /> EHD 46-07.025 \1 - SERVICE REOITti$T FORM �1 <br /> REVISEgr,S-02' - - . <br />