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Sc h vxl� 11 �y�.333, <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT�Zo9/ <br /> SERVICE REQUEST <br /> e of Business or Property FACILITY ID# RVICE RE E r# <br /> Anc, A)'LPr^ 3�72 <br /> OWNER/OPERATOR (� CHECK B BILLING ADDRESSO <br /> ll� LuF57, CoA :-i <br /> FACILITY NAME 1-I/t n L , <br /> A M J P n', <br /> i95- l/.J Lt,.Sati -. At( <br /> Street Number Direction Street Name CHIN Zip Cade <br /> HOME Or MAILING ADDRESS (if Different from Site AddresS) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ev. APN# LAND USE APPLICATION# <br /> PHONE#1 E%r. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK N BILLING ADORESSO <br /> N tr A.,e�, <br /> BUSINESS NAME ( PHONE# Z I j'To1 78 <br /> HOME Or MAILING ADDRESS <br /> k 3Ulo W , t. a w PA Ss Q D � tj� <br /> STATE E� Zip l AS <br /> CITY `1 �+l <br /> CpN.i �na <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 <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 also certify that 1 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 E /Paws. <br /> APPLICANT'S SIGNATURE: '�%` �/ DATE: d r1-;27lG 9 <br /> PROPERTY/BUSINESS OWNER❑ OPERiTOR/MANAGER ❑ OTHER AUTHORIZED AGENT AGe,-� t 5e C'- I ` <br /> IfAPPLICANT 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 t0 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. T <br /> TYPE OF SERVICE REQUESTED: t-fST pQ E�72-m F! ir CENE <br /> COMMENTS: r'U L Co'.' • fD t . A C v P n n a +^ Mp`I cz 7 2004 <br /> L <br /> SF E Sp` 60 (o O oZ SAN JOAQU1 A COUVIVV- <br /> �THp PPRTMEt3T <br /> H <br /> APPROVED BY: V t EMPLOYEE#: 3 Z DATE: <br /> ASSIGNED TO: TAC-rS o„J EMPLOYEE#: 3'7,Z DATE: 5' 27 O <br /> Date Service Completed (if already Completed): SERVICE CODE: I C/ P/E:a3. O g' <br /> Fee Amount:VX79-100 Amount Paid a Z�, Payment Date �Z O 4 <br /> Payment Type Invoice# Check# a Received By: <br /> SERVICE REQUEST FORM <br /> REVISED 65-02 <br />