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UG/ Lr: <0u4 1b; 24 404!71.. tIJV1KUNIv NIHL HLHLIH <br /> -41 'IN!)( C(N-VWUNMENTAI,k1EALTR 11T'X'ARTMENT <br /> SERVICE REQUEST -' <br /> Type of Business or Property _ SERVICE REQUEST# <br /> O�lc� 1 NDI�T rti✓ =FACILrTY <br /> OWNER/OPERATOR <br /> CHECK It BILLING ADDRE$S13 <br /> FACILr(Y NAME <br /> SITE ADDRESS C <br /> O $beet Num or DI tcyD <br /> N� �� qS Z�I <br /> s ! Na "/ Ci 21 God! <br /> HOME or MAILING ADDRESS (If Different from Slte Address) <br /> Slreel NumEer Street Nam <br /> CITY STATE ZIP <br /> PHONEM ExT- APH# LAND USE APPLICATK)N# <br /> Bio ) 82 - �3 - 2 -U� - � OW026s <br /> PHDNE 42 Exr. ROS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRE$s1E <br /> BUSINESS NAME PHONE# <br /> 2l <br /> HOME at MAILING ADDRESS FAX <br /> ( 1 <br /> CITY Gel'% STATE GA ZIP 1 <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 ENVMONMENTALHFALTH DEPARTMENT hourly charges associated with this projector <br /> activity will be billed to me or my business as identified on this form <br /> I also terrify that I have prepared this application and that the work to be'perfortned will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stgndards,STATE and <br /> F�EDERA 'law <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSIPESS OWNER❑ rr�OOrdATOR I MANAGER ❑ '07HER Au rHORIZED AGENT <br /> lJAPPLICANT is not the B7ll1,VG PARTY proof of authorization to sign is required Tirt c <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 environmentaVsitc 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 /> TYPEOF SERVICE REQUESTED: /I/I*+14 Q ) <br /> COMMENTS' <br /> R ECR V E L <br /> JUL ? 0 200 <br /> SAN J.,;. . 'oufv <br /> APPROVED 9Y: EMPLOYEE O DATE'��. .j tfj117.- <br /> ASSIGNEDTO[ EMPLOYEE#: L DATE: <br /> Date Service Completed I already completed): SERVICE CODE: s� PIE: Z(pO2 <br /> Fee Amount: Amount Paid /, — Payment Date a <br /> Payment Type Invoice# Check# 51& L; Received By. <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6502 Post-it'Fax Note 7671 C,12;7 <br /> Qaq�a►. <br /> To St� from <br /> GotoePl. .a A.r Co. SJ_(2-0 E/r <br /> Phone N Phone ff Z yl�•O ^3 �0 „w. <br /> F.4 '?/C, 21 7 0 61 <br /> Fes 0 6 v-0 <br />