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SERVICE REQUEST <br /> Type of Business or Property <br /> FACILITY ID# SERVICE REQUEST# <br /> � <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS <br /> FACILITY NAME ' <br /> SITE ADDRESS Z :� .R�k ` g- - <br /> 0Street Nu wer Dlrectk <br /> Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site ddress) C� J k�t.t-N <br /> �. Street Number Street Name <br /> CITY STATE zip '2 5—,7 <br /> CA <br /> PHONE#1 <br /> EXT. APN# fl rI p Zl d LAND USE APPLICATION# <br /> {qm ) 77 27 `x ' Co;.. 1� 0—e <br /> PHONE#2 ExT• BOS DISTRICT LOGATION CODE , <br /> { ) <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> PHaNt:# ExT. <br /> BUSINESS NAME �` O �b 27 • ~ <br /> HOME or MAILING ADDRESS lV FJuc# <br />' CITY STATE ZIP <br /> r Lp <br /> I BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized ag nt of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL 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 /> t 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 /> t COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> } APPLICANT'S SIGNATURE: DATE: 2- 7-'i <br /> q PROPERTY I BUSINESS OWNER® O ERATO / NAGER ® OTHER AUTHORIZED AGENT® S L <br /> Ifl1PPLlCANT is not the B LUNG PAR 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 /> ` HE DEPARTMENT as soon as it is available and a� �same time it is <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL H <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: ✓�����, 7iZ/D$ �� ��� • e OOVN� <br /> I r ao�QU�O%N iPV g <br /> rry <br /> � N <br /> APPROVED BY: EMPLOYEE M DATE. <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: <br /> Date Service Completed (if already.completed): <br /> SERVICE CODE P i <br /> Fee Amount:. f Amount Paid ` Payment Date 3 3 <br /> Payment Type t' Invoice# Check# a �`� . - Received By. <br /> r <br /> I <br /> SERVICE REQUEST FORM <br /> EHD 48-01-025 <br /> REVISED 6-5-02 <br />