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OA1N JkJAVU11 VU1NI X JP1N V 11CV1N1V1L'1N IAL 11L'AL L'YA1C11WEIN1 <br /> SERVICE REQUEST W <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> & 6L3 cVF0CD .sales :ESR0032- 19D <br /> OWNER/OPERATOR <br /> /� CHECK It BILLING ADDRESS <br /> �a r -n a b it ,Fd 5 A6/'N <br /> FACILITY NAME � A T /-I lZ O ,{ S+ �, r p 0 D M R r <br /> SITE ADDRESS rDRESS \n/ q 0 /�J T-A Cr E P,d 1\A A-A) j5 C^ 9 S 3 3 6 <br /> T V O 0 Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#i Exr. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR G-- G kfNe./' a / <br /> CHECK If BILLING ADORES, <br /> BUSINESS NAMEPHONE# ExT. <br /> ! T _ CDNTRAC7ORS 9 *61 - 633° <br /> HOME or MAILING ADDRESSFAX# <br /> S 35- W / 6 W /Vt Dr ( ) <br /> CITYi S T O C A. TD 1-2 C? <br /> �-� ZIP CJ <br /> BILLING ACKNOWLEDGEMENT: 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 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 FE RAL la s. <br /> APPLICANT'S SIGNATURE: £ DATE: 1;h ^�� <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANA OTHERAUTIIORIZEDAGENT�. A-5 S( All <br /> If APPLICANT is not f BILLING PARTY P of 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/ - �O`hcssment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available an� C it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: /y .5 re_ C J—/ 0 Ill `l C� f/ <br /> COMMENTS: R E >77 0 ✓ / v� 9- L 7� i S / / f^ r / tD e ✓- l Y' 2 'YL G G� f POV\N SE NGEN\DN <br /> R / mc e 2 X / sTvv �� rS� etnS eys odeY e <br /> D � e 1A ser a ,A N�\nDa <br /> APPROVED BY: EMPLOYEE#: DATE: L24 <br /> z <br /> ASSIGNED TO: N` EMPLOYEE#: DATE: 11 <br /> Date Service Completed (if already completed):--- SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid �`7 Payment Date l / d v <br /> Payment Type ✓ Invoice It Check# (o Received By: <br /> n <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br /> v <br />