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a` <br /> :7111\ UV'M%ZLJ LVU1F11 l:il\T 1xvw1 N ITS L'1\1 t1L 11L't1L I Jvrr H1'111'1L`1\1 <br /> '--- SER�lCEtEQUEST <br /> _.: <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER 1 OPERATOR <br /> le-11 CNECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITEADDRESS �j��� <br /> Street NumberTO!t€on T� Str N me G€ Zi Co`d!e <br /> .HOME or MAILING ADDRESS (If Different from Site Address) �{�j�.� �%` �e Co\J <br /> Street Number Street Name <br /> CITY �otJ •�GjG+^�\�1� STATE`A � ZIP <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> /4* 5._ CHECK if BILLING ADDRESS <br /> .",/, X " <br /> BUSINESS NAME PHONE# ExT. <br /> Z�Wlr / <br /> 3 <br /> CITY ��5 GOv9r_ 'F_' STATE 4W 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 EmORONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or 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 t wor to be a ormed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST nd FE la <br /> APPLICANT'S SIGNATURE: DATE: �/ <br /> PROPERTY I BUSINESS OWNER® OPERATOR/MANAGER © OTHER AUTHORIZED AGENT .�je yp Y10 02 <br /> If APPLICANT 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 represenlilive. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> I .G_ _7 0 <br /> A�y0p0�yM�ANN <br /> APPROVED BY: (H p�P EMPLOYEE#; DATE: <br /> © Lt ��r S ZU G� <br /> ASSIGNED TO: ��C D7TD EMPLOYEE#: S--C7 � a° DATE: S Q a Ei <br /> Date Service Completed (if already completed): SeRvici COBE:..: .,, P!E: <br /> Fee Amount: C g ,o-D Amount Paid CnPayment Date S Q� <br /> Payment Type >✓ Invoice# Check# `�3 Received By: <br /> j EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />