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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH-DEPARTMENT <br /> L — SERVICE REQUEST ....i <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS ��/� �•/ q CZ3� <br /> Street Number Direction Streel Name Ci l/ZI LOAe <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 E" . APN# LAN USE APPLICATION# <br /> 6o�71 <br /> PHONE#2 ExT BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ^- Y� 2 CHECK It BILLING ADDRESS <br /> BUSINESS NAME •LJ !I <br /> 1 PHONE# <br /> /wo f �th" - <br /> HOME Or MAILING ADDRESSFAX# <br /> ( - ) -0 23 <br /> STATE ZIP Cz¢J <br /> �0 <br /> -7(, 3 /L _ _ _ „/ / y or business owner, operator or authorized agent <br /> his r same, <br /> .�'Q�6'R/(/�r- ��1 �[ iALTH DEPARTMENT}1011rly charges associated with this project Or <br /> h1/ 1 to be performed will be done in accordance with all SAN JOAQUIN <br /> DATE: �/•.//L� G� <br /> OTHER AUTHORIZED AGENT❑ <br /> Drizafi ro sign is required Title <br /> plicable, I, the owner or operator of the property located at the <br /> results, geotechnical data and/or environmental/site assessment <br /> i DEPARTMENT as soon as it is available and at the same time it is <br /> `'( ,l_Ot+A,r•U�/ y_T`VIp,pl,_"-`TI 0�1.- (.I*�[µ,.r,,uh� T <br /> j PAY ENT <br /> RE IVEC <br /> JJUN 2 5 2002 <br /> SAN JOAQUIN COUNT% <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEAT nfmiO.;, <br /> EMPLOYEE#: �/ C DATE: 6 <br /> EMPLOYEE#: l� DATE: <br /> SERVICE CODE: PIE: <br /> Payment Date <br /> Check# Received By: <br /> SERVICE REQUEST FORM <br /> EHD 48.01-025 <br /> REVISED 8.5.02 <br />