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SERVICE REQUEST': <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST I <br /> OWNER/OPERATOR <br /> Cr _l �C CHECK It BILLING ADDRESS <br /> 1 <br /> FACE"NAM r lel k` f 65 <br /> SITE ADDRESS I L q rlQ /'Itretbr t�7e La-1-1A ror 15-330 <br /> Street Number Direction lStreet Name city le <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> IO I es` Street Number eet N <br /> CITY STATE ZIP <br /> kh'e eki 9 <br /> PHONE#I ExT• APN# LAND USE APPLICATION# <br /> �0 18T'W^1,- 4k\ (0( 0 3 y <br /> PHONE#2 Q,t� EXr. BOS DISTRICT LOCATON DE <br /> 1951 ) 500- 516 3 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REOUESTOR , <br /> CHECK It BILLING ADDRESS <br /> 0 <br /> BUSINESSN E PHONE# ' <br /> V �o�s l'nc rv337 <br /> HOME Or MAILING ADDRESS FAX# <br /> Crry I ],G \ srATE / n zip O5 ' <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,lopeerator 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 /> activitywill 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATUREN.JLGY.�. DATE: 6c LEyp <br /> -/9-6$ I <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑. OTnERAUTHUPRIZEDAGP,NTi9&,.-,V, , raZha-ry-T <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�enviro ntal/site assessment <br /> � <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT aS soon as it is Y � at the same time it is <br /> provided to me or my representative, <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> CE1VE M ably <br /> FE 08 s P E <br /> ES � <br /> �AAY 2 9 20 H�0P � <br /> 117k <br /> SNt�OAp MEQxL <br /> ACCEPTED BY: O / v [ ,O _A EM C)a DATE: 'TZ,O cte <br /> ASSIGNED TO: N 4-( .� EMPLOYEE#: ^ �? U DATE:.5' () Q <br /> Date Service Completed (if already completed): SERVICE CODE: c18' P 1 E: p� <br /> Fee Amount: c� .�J Amount Paid PLTOayment Date 0 <br /> Lir <br /> Payment Type ,j Invoice# I GTC1 0 Check# -1 Received By: <br /> EHD 48-02-025 'kGb ��-' lag► � a9 0� a (� :/ <br /> REVISED 11/17/2003 / �-ry �^ <br />