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7 - 1. Al N J UAQ WIN k-UU1N'1'Y L'N V1L1iUNkVIEN'1'A1,tiL:AL"1'H 1)tVA1,CrMt:N"1' <br /> W • <br /> 10 SERVICE REQUEST 1 <br /> Type of Business or Prop J FACILITY ID . .-SERVICE REQUE57 <br /> f � /�jj���JJf ry „�•sitn �,'��'+'� w��f��yt p ,t°Ta�,� a , �' ' � �7 <br /> OWNER/ <br />� <br />{ /OPERATOR } <br /> l2� /J CHECK If BILLING ADORESSS <br /> FAcILITY NAME. LLL...!!!111 ✓ �[� <br /> r SffE A ESS <br /> I <br /> 7T4 <br /> tr <br /> ;x <br /> Streel Number I ec to r' <br /> - Nam <br /> c <br /> . - CI ZI Code <br /> HOME or MAILING ADDRESS (if <br /> (if Differee]ntt from Slte Address) <br /> r. Street Number <br /> FStree a e <br /> CITY d� U SATE ZIP <br /> PRONE#I ExT APN# LAND USE APPLICATION <br /> 711 01, 2-T7 <br /> r . <br /> PHONE 01 Err. BOS DI5T21CT, � �#;3JIk LOCATION CODE <br /> ' I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> AiAT <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME /, r� ry Exr. ! r <br /> : PHUNE# gt16 �oO�b <br /> HOME or MAILING ADDRESS FAX# <br /> PAC 9�426P W6 <br /> CITY -rZ STATE 64 <br /> ZIP <br /> BILLING ACKNOVMEDGEMENT: I, the.undersigned property or business owner, operator or authorized agent of same, ° <br /> acknowledge that all site and/or project specific ENVIRONMENTALHEALTH DEPARTMENT hourly charges associated with this project or i <br /> 'activity will be billed to me or my business as identified on this form. <br /> Li <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, TE d L laws. Y <br /> APPLICANT'S SIGNA DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPE /MANAGERX OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT"Vol ARTY 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 /> inforrpation 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. ` N'C <br /> TYPE OF SERVICE REQUESTl sO�!1 S(�( f'k (� I S- <br /> D: {� <br /> CONId1EHTS: ,,_ 3- t©, /G. / !`t 0 � 2do L. <br /> �oPa \�NSE <br /> orb <br /> APPROVED t3Y r 1 k <br /> �t f <br /> � EMPLOYEf�# �'l r � 1 DATE + �* <br /> ASSIGNED TO: ,EMPLOYEE#: Y"� yt . <br /> ot <br /> Date Service Cornpieted (if alreadE completed) t" - r SEItY10E CODE r 'y <br /> AmPayment'DateFee`Amount Fy �E <br /> Pa ont T ]nvolce# ` Check# '' Receivt3d By'-'. ,. <br /> ym Type p.. <br /> Erna 48-01-025 <br /> REVISED 6;5-02 SERVICE REQU$ST FORM . <br /> � y. <br />