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SAN JOAQUIN ��UUN'i'Y LNVIKUNMLN'i'AL HLAL'l !)EYAR'i'MLN'I' <br /> SERVICE REQUEST ` <br /> } f <br /> Type of Business or Property »;.-�`; FACILITY ID# SERVICE REQUEST# <br /> 6.r2a0 �1565Y <br /> OWNER/OPERATOR <br /> Jos,6 V, fq ��"(>j-{rS CHECKIF BILLING ADDRESS 0 <br /> FACILITY NAME V 4 V FA�2-M.S <br /> SITE ADDRESS (44.54 /J 80 L.0p 9 24-0 <br /> Street Number Direction Street Name CII zipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) 88 <br /> S LJ 0InT l 15 Street-Numb er <br /> Street Name <br /> CITY Loo ! STATE Zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> {oh ) 43L -65b& 063 �" � I r "'e� 03�- <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> { ) <br /> CONTRACTOR! SERVICE REQUESTOR k <br /> Rr`puesTOR <br /> CHECK If BILLINGADDRESSE <br /> BUSINESS NAME ,4 f PHONE# ExT• <br /> �r['L o,., /Ui LI2P 2v�1 ?34 -66( 3 <br /> HOME or MAILING ADDRESS FAX# <br /> UK Z-1 vo ( ?,Lfl ) "334 -07Z'3 <br /> CITY LOD 1 STATE C zip 952-41 <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 ENVIRONMENTALHrALTH DL•PARTMENThourly charges associated with this project or <br /> activity will be billed to aIle or my business as identified on this form. A <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,STA FEDERAL laws. � <br /> APPLICANT'S SIGNATURE: <br /> DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AuTiiouizEU AGENT❑ I <br /> If APPLICANT is not the BIL NG 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 ENVIRONMENTALHEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE of SERVICE REQUESTED: dur i Gt l� �(,(� GGP�G/ '� (:faA1i <br /> COMMENTS: i -5% ,-WbJ , REMIVED <br /> OCT _ 7M <br /> &AN JOAQUIN COUNTY <br /> 0 Q `PUBLIC HEALTH ALTH I0IV15lQN <br /> !, CES <br /> NMENTRL HE <br /> APPROVED BY: T). � � � � EMPLOYEE#: f3 / DATE: <br /> ASSIGNED TO: �.- YrJ�v/,LJi� EMPLOYEE#: �3� � DATE: f'0/0�/d3 <br /> Date Service Completed (if already completed): SERVICE CODE: `,9' P I E; D <br /> I <br /> Fee Amount: AK 06 Amount Paid } -�- Payment Date <br /> Payment Type Invoice# Check# e1& <br /> 7QZ9 Received By: <br /> RHD 48-01-025 <br /> SERVICE REQUEST FORM <br /> 8-5- <br /> REVISED 6-5-42 <br />