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F *. <br /> JAiV JUA(1UtN l UU1V l X L'N V1KUN1V1t:1V'l'AL rik:AL'4H 1J t'Alt l iV1LIN l" <br /> SERVICE REQUEST 0 <br /> Type of 134iness or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERAT R 9 <br /> -a- t, CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME �L_ <br /> SITE ADDRESS Direction <br /> Number <br /> l3/ 6 i nuc <br /> Street Street Name city Zi Code <br /> Hoo MAILING ADDRESS (if Different from Site Address) <br /> , <br /> r 7 ^ !/,5- Street Number Street Name <br /> CITY ( SE ZIPS <br /> PHONE#t `14 Ext. APN# LAND USE APPLICATION# <br /> i ( Zv?) 23, `-35-?-1 ��-/�o-- 3� P,4--02- 0 <br /> PHONE#2 Ext• BOS DISTRICT LOCATION CODE <br /> (Z0 ) 0 <br /> CONTRACTOR/ SERVICE REQUESTOR Fr�yy <br /> RE.QUESTOR-^—� ^, CHECK if BELLING ADDRESS�7 <br /> �Clft'1 d1�`M�t2 <br /> BUSINESS NAMED PHONE# �3 Ext <br /> HOME or MAILING ADDRESS FAxx#1 <br /> f' 0. <br /> CITY J�e e471� STATE 041- ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of sante, <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 be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAT- d FE RA laws. <br /> APPLICANT'S SIGNATURE: DATE: 3/7/� 3 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 environmental/site assessment <br /> information to 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. <br /> I <br /> TYPE OF SERVICE REQUESTED: Sd I 5l/L� / Gam- Cly-- <br /> COMMENTS: ✓ll �G3 3/P�lU3 RECEIVED <br /> p� �I�trrte�wrj <br /> MAR 13 2003 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH S€RVICES <br /> ENVIRONMENTAL HEALTH OMSION ' <br /> APPROVED BY: EMPLOYEE DATE: 3 — (3 -3 <br /> ASSIGNED TO: � p . EMPLOYEE#: LJ DATE: 0 <br /> Date Service Completed (If already completed): j3 O <br /> -TSa avlcE CODE: a PIE; <br /> Fee Amount: ~� OO �---_,Amount Paid 1 ��— Payment Date <br /> Payment Type Invoice# Check# /,FP Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />