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SAN IOAQUIr —,UUNT, ENVIRONMENTAL HEALTti DEPARTMENT <br /> % ' SERVICE REQUEST SERVICE REQUEST# <br /> FACILITY ID If 003 <br /> 3 <br /> pe of Business or Property <br /> CNECK if BILLIN <br /> ADDRESSe <br /> OWNER 10 RATOR <br /> FACA NAME =' O, ZI Code <br /> Cit <br /> SRE ADDRESS/ S, A 1am <br /> LJ SveeI Nf pal Slr¢¢L Nagle <br /> HOME or MAIUNG ADDRESS (If Different from Slte Address) l O Q� reet Number ZIp r <br /> 40 <br /> CITY LAND USE AP LIGATION# <br /> Exr. APN# _ � C �� /-7 <br /> PHONE <br /> (.IZYI) Y/sY — 33SL19 DOS DISTRICT LOCATION CODE <br /> ExT. <br /> PHONE#T <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTO <br /> CHECK If BILLING ADDRESS <br /> REQUESTOR <br /> PIIatE A EXT. <br /> BUSINESS NAME LJ.a a - `3 3`raZ <br /> Y FAX# <br /> HOME or MAILING ADDRESS ) 36$ —O <br /> O J ZIP <br /> ST rZ� <br /> Gln <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent or 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 /> I 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,Standard STATE and FERAL law . r <br /> APPLICANT'S SIGNATURE: j/ / <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ ffTHER AurnORIZED AGENT <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 representative. <br /> TYPE OF SERVICE REQUESTED: A I-I rn �p,Y wEp <br /> COMMENTS: O 9 � <br /> PQ�tN SE(M*E a <br /> v "� ``R` '* .�V35`°t eaaHka��H OM <br /> C4YrOM.11+t c5i, 2�! ��e'/Jl�;7.� VtFpNM�N� <br /> 'V/ / FN �OQ <br /> /7 ! <br /> APPROVED BY: EMPLOYEE#: O DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Dale Service Completed (If already completed): SERVICE CODE: P/E:/ <br /> Fee Amount: i.itqOD Amount Paid - <br /> 6j� Payment Date <br /> Payment Type Invoice# Check# <br /> Received By: <br /> EHD 46-01-025 / ?l ;�oy 30M. j <br /> REVISED 6-5-02 SERVICE REQUEST FORM <br />