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JAIN JVA%JU11P' "UINIY r-1NV1KV1V1V1VIN 1AL,"nALI " 1/C.YAKILVIL'1N1 <br /> ~' SERVICE REQUEST <br /> Type of Business or Property FACILITY ID If SERVICE REQUEST# <br /> X238 <br /> OWNER/OPERATOR <br /> Car <br /> 10(1 Lri 10 <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS ` 3,r�Q f IC /A „ <br /> She tt Number Direction 6 S/ire t Name +lJ city ZI Cole <br /> HOME Or MAILING ADDRESS (I Different from Sl te Address) <br /> I^ <br /> el Cv)Q r Street Number Sheet Name <br /> CITY 1 Ie4i Qnivn (`,/{ gL� l STATE ZIP <br /> PHONE#1 1 En, APN# V LAND USE APPLICATION# <br /> ( slo') 1.43 FA -d2oo2nS <br /> PHONE#2 EXT" BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Cgr �oj ur I1 !) CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> el�llble rt 1kin . <br /> HOME or MAILING ADDRESSFAx# <br /> ar•r0 <br /> CITY (Qq1 iin4tn (.A 11+�99 <br /> STATE ZIP <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 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 /> 1 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,STATE and FEDERAL laws. (� <br /> APPLICANT'S SIGNATURE: 002" &4;7laDATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> i <br /> (f AhPIJCANT 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 /> TYPE OF SERVICE REQUESTED: LI 4LAI d 4 5ft�, F /1 e c K ?w V EQ <br /> COMMENTS: <br /> �������y,� <br /> NSP <br /> ONpLN�� <br /> EMR(3bo HEAIZN <br /> APPROVED BY: `/'(,/•/t 1, 0 �•,�I/ EMPLOYEE#: -�� Z DATE: I Z <br /> ASSIGNED TO: J� EMPLOYEE#: I DATE: <br /> Date Service Complete (if alrea y completed): SERVICE CODE: 51-)- P i E: Z p <br /> Fee Amount: )�� Amount Paid 1l Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-035 SERVICE REOUEST FORM <br /> REVISED 6-5-02 <br /> v <br />