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SAN JOAQUI :OUN'1'YLNVIKONMLN'I'ALIILAL� DLPARTNIENT <br /> �. <br /> SRRVICR REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ OPERATOR <br /> CHECK II BILLING ADDRESS <br /> FACILITY NAME l <br /> SITEADDRESS �p <br /> r1 ! l ' Sbeel Number mrceuo� /` / Iree H r�rM t�ty Zip code <br /> HOME Or MAILING ADDDDRREESSY„(it Different from Site Address) <br /> Slreel Number Street Name <br /> CITY STATE zip <br /> PHONE41 EAT' APN N LAND USE APPLICATION H <br /> czu � 1 O,3f,, - `Z4 v7o - o4� r�A v "� - 21 -? <br /> PHONE#2 EXT. DOS DIST ICT LOCATION CODE <br /> t ) <br /> CONTRACTOR/ SRRVICR RRQURSTOR <br /> REG U STOR <br /> CIIECK II BILLING AnDRESS11 <br /> cp <br /> BUSINESS NAM ,l EAT. <br /> 5l )AL Y� PHONE# _ a <br /> HOME Or MAILING ADDRESS FAT(# <br /> v ,)--(- U f 1 354-017Z 3 <br /> CITY , t\ STATEi A zip �•��) iy� <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 DL-PARTMENT hourly charges associated with this projector <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Coder,S1 rds,STATE and PED�ws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNLR❑ 'L'RATOR/MANAGER ❑ OrHLR Au-nionELRD AGRN-rd %f//L w14 i111-e <br /> If APPIJCANT is I l th !LUNE;PARTY proof of authorization to sign LT required _ Tule <br /> AUTIIORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator or the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/silt assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and a�c same time it is <br /> provided to me or my representative. M� Q <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: �'� <br /> 3 PUGS lN�)UN S. <br /> �'lw.QO ENNP NN`N`P�Nf.PPH�NS`ON <br /> A irr�� <br /> APPROVED BY: 1 EMPLOYEE#: L ` .� DATE: 8 Z) U 3 <br /> ASSIGNEDTO: EMPLOYEE#: IU DATE: <br /> Date Service Completed (it already Completed): SERVICE CODE: s Z Z X P/E: Z G O.r <br /> Fee Amount: Amount Paid Payment Dale <br /> Payment Type Invoice# Check# Received By: <br /> EHD 4901-025 SERVICE REQUEST FORM <br /> REVISED 6-502 /!figIA <br /> q1510,3 <br /> 15 _ O ( _ <br /> �l - l�(r H-.V. "�.lJ� 1 1 <br />