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JUL-UZ-_-U0SANJ0AQLT1N COUNTY EMM% iENTAL HEAL-_DEPARTMENT <br /> - -. <br /> P.02 <br /> SERVICE REQUEST <br /> Type of Business or Propertywx,fapj ITY ID# SERVICE REQUEST# <br /> Type of 9wlnw or Pro99rty F 11tS1f IDC fi�AUEiT D <br /> OWNE / R <br /> OWN"1 OW01 F4 CHECK if&&ft9*ffbQE<S <br /> IN <br /> FACILITY <br /> FKurr NAME <br /> SITEADERESS. <br /> i <br /> treet Number Mrasbion <br /> HOME Or � �f0�i+Dh1�QE9hMddress) <br /> "___=dress) tree ame <br /> CITY CrTT �Q.b � TATEC-A 1,:k to <br /> Lwo U�f A►ttx�►roM i <br /> PHONE#1 poq 01�2 7 (G/0 W' T AP # LAND USE APPLICATION# <br /> ) 7 7 OI �"+� r E UOCAn=GSE <br /> PHONE#2 ExT. <br /> 1 ) CO <br /> NTRACTOR / SERVICE RE QUESTOR <br /> REQUE r 1f�oue� <br /> �t 0 OCHE ADDRESS <br /> CO- <br /> BUSINES c 6�� E-• <br /> SIAM OilZ,v r' <br /> HOME or VIAII <br /> BILLING Ily of w8kow Mw,comw R awwtmw apm 414WA a0�Iha 4.tom India Furp""C,61 <br /> CITY PuRJC MFaC1H WADI DNRW1 bMW 119 I P <br /> BILLING:(�1 ` ED EME er ' ropert or usiness dw r, operator r a thorized agent of same, <br /> acknowledl r r ct e c opt rhn � with chic pect or <br /> activity wi11PRQFF�bil e to e o b�s a this farm. p <br /> r��~� ,.�„�.,� Tru. <br /> I also certify that I have prepared this a licati a a e� � e per e JW4& �� � UIN <br /> COUNTY i �iMOo O1drmbM J°wun Wwri itaClt>>t>At 6EAt+�Csti EiMlahaJ�ll�liu►IN DrnOoM as Toon <br /> �+r <br /> u t d+ow dad RM waa rn.t b laa b llM or of �� <br /> APPLIC ATE: <br /> TYPE 5Uri=PJMUE rm: , <br /> PROPERT /BUSINESS U&NER <br /> COMA"PPLICANT is not the BILLING PARTY,proof of authorization to sign•is required Title <br /> AUTHO UZATION TO RELEASE INFORMATION: When applicable, I, the.dwner or operator of the property located a the <br /> above siteaddress, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assess ent <br /> infoimati n to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ais soon as it is available and at the same time t is <br /> provided o me or my representative. i <br /> I <br /> TYPE OF SERVICE REQUESTED: <br /> CbMMENTS: <br /> 1xirEcroK�SIGMA <br /> Ail"°Ym 9r; A:C� Datil: Diad _3 <br /> AmANO T0, k 3 53 0 �- <br /> Ou4 srmu ComploW 0 aftmty ool"PkW4 S�orazCooe ) P!E�(7dJ <br /> Ftc Amount Awouct Pziid <br /> APPROVE Y T 0 �E# �H Br <br /> ASSIGNED TO: EMPLOYEE#: , DATE: <br /> Dote Service Completed (if already completed): SERVICE CODE: P TE. <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6.5-02 <br />