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IAP[ JVA U114 LVVI-N1 I Jr1`)r1iCLJ1'11r1i11'qitiLis: — <br /> 9 SS- 7& 7 Foe-�91 i.-SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# . SERVICE REQUEST# <br /> Sao 3q / <br /> OWNER OPE TQpOR CHECK IfBILLING ADDRE55❑ i <br /> ly � <br /> FACILITY NAME <br /> SITE ADDRESs,,�2' ,1 „2JG� " —4y n e S tr� R503 X(NL QA <br /> Street Number Direction Street Name Ci Zio Code <br /> HOME or MAILING ADDRES�,Af Different from Site Address) <br /> (.�`�r-1'gz� IQ <br /> 1.—. 1 ! S Street Number vJ1fe 1` <br /> CITY STATE <br /> E APPLICATION� b <br /> EXT. <br /> {HONE#, - is b— <br /> b-3 �� <br /> P f/Ef� ExT. BOS DISTRICT =LOCATIONE <br /> c � bD - 3bb <br /> NTRACTOR 1 SERVI E REQUESTOR ---� <br /> REQt1ESTOR COCHECK'1f BILLING ADDRESS❑ <br /> Exr. ! " <br /> BUSINESS NAME <br /> PHONE R <br /> MIN <br /> HOME Or MAILING ADDRESS FAX# <br /> - ( 1 <br /> CITY STATE' zip <br /> .rte <br /> BILLING ACKNOWLEDGEMENT- I, the undersigned property or business wwner, operator or authorized agent of 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,Stan ds,STATE and FE laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑, OTtIER AUTHORIZED AGENT❑ <br /> IfAPPL1C,1NT is not theB1LLJNGPAR proof of authorization to sign is required Titie <br /> AUTHORIZATION TO RELEASE ]INFORMATION: When applicable,I, the owner or operator of ��ied at the <br /> above site address, hereby authorize the release of any and all results, geotechnical.data and/or env ssessment <br /> information to the SAN JOAQUIN COUNTY ENviRONMENTAL HEALTH DEPAR'T'MENT as soon as it is available and ai the a time it is <br /> provided to me or my representative. <br /> SEP � <br /> TYPE OF SERVICE REQUESTED: Lr QU JC�t <br /> f �A SiZ- C D A -L 1-4-T7 0^J SAN 14RA IN COUNTY <br /> 1 COMMENTS: <br /> 773 \./'ElLf F. <br /> 4A4� J 7(� t1nlA��.C"T -,�} � /�(D►�f LIQ. <br /> Cp I v t4 s S ��< ►� C9– 6L O 6-- <br /> bp--c <br /> -, <br /> ACCEPTED BY: ji- tJ [ y EMPLOYEE#: ©"3 DATE: Lf' l L f <br /> ASSIGNED TO: ,,I}•tf EMPLOYEE#: U DATE: f CE <br /> Date Service Completed (if already completed): SERVICE CODE: 0� j PIE: 42 -02—Fee Amount: Q Amount Paid Payment Date {� <br /> Payment Type Invoice# Check# 79V a— eceived By: <br /> EHO 48-42-025 R,FOF NI(Gbld tl F???d) <br /> REVISED 11/17/2003 <br /> f <br />