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SAN JOAQUIN (. NTY ENVIRONMENTAL MAL'I'll PARI WWI' <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �pOn 347 � <br /> OWNER/OPERATOR C <br /> STaVi5 RM e7rz.�,,_ ( CHECK if BILLING ADDRESSI� <br /> FACILITY NAME rte+ <br /> SITE ADDRESS y675 1 A-E 12,Qd rE GaV 5' j�(�rUaJ QJ�L 1 Z <br /> Street Number Direction Street Name City-�/ sv n ZI Code <br /> HOME OT MAILING ADDRESS (!f Different from Site Address) ��CMZ MSI M"4 ray - <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. <br /> BOS DISTRICT LOCATION CODE <br /> 1 / CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I VIE ��/ <br /> �1J1 I CHECK[f BILLING ADORE Ss <br /> BUSINESS NAME �O� 4,(- <br /> 1 iTY PHONE# EXT. <br /> is <br /> HOMt:or MAILING ADDRESS FAX# i <br /> 3 2(0o ( 201) 33�-073 <br /> CITY STATE <br /> '4 Zip q S 1 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 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 to be perforpied will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. �7I <br /> APPLICANT'S SIGNATURE: r <br /> DA t : / Z' 3 <br /> Pltol'tmitTY/BUSINESS OWNER❑ OPERATOIt/MANAGER ❑ O'ruER AuTuoI2I'LCo AGISNT❑ <br /> If APPLICANT is riot the BILLING PARTY,proof of authorization to sign is required Title i <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 /> TYPE OF SERVICE REQUESTED: -ID IV <br /> COMMENTS: <br /> 20'4;�- -� SAN JOAQUIN COttNN <br /> /a'�� �� E�iV4R0�ME�TAL HEAtiS p���1D!`1 <br /> 3 <br /> APPROVED BY: r EMPLOYEE#: I DATE: <br /> ASSIGNED TO: EMPLOYEE#: S' DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I PIE: 9) <br /> EeAunt: --� Amount Paid f' [�C�� Payment Date Type ✓ Invoice# Che66ck# � � j Received By: <br /> EHD 48.01.025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />