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NAN JOAVUIN I OUN'l Y LNVIKONNILN AL t2L'AL1 rl ULrAK l IVII5N L <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER 1 OPE=RATOR C t'c'¢- r.! h'J A��� <br /> L CHECK If BILLING ADDRESS <br /> FACILvy DAME 1�\I f'LQ (� Q(Z'.) trE(2- C S <br /> SITE ADDRESS I�3��-� �-q �. �L.t�ST <br /> Street Number I Direction I Street Name Ci ZI Codu <br /> HOME or MAILING ADDRESS (If Dtfferent from Site Address) 4~}-5- VJ , <br /> Street Number 5tre0t Name <br /> CITY r.`� .�y STATE C"^ zip <br /> PHONE#1 APN# 2 _ -p LAND USE APPUCATION# <br /> ( Za°7! 1 $31/1— oaoS mss-- I'fi'ti --tom Ph-Itoav��1 � P�i�c�oa�� f ..� <br /> NIONE fit ExT BOS DISTRICT LOCATION 00DE <br /> c ',Il( <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTQR <br /> CHECK if BILLING ADDRESS El <br /> PitoNt <br /> BustNESs NAMEErr.� � Svc- C��n Nvt�aNn1 + d�� zap 3U`i- o3-1 S- <br /> HOME or MAILING ADDRESSFAx# <br /> �{o� a Psi ST , <br /> (-7,011) <br /> CITY lrt7�; STAT€ G� ZIP cK y.t.-4 a <br /> BILLING AC KNOW LEt)GEMENT' I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific I N pN'+INE <br /> E 'AAL'Ni DEPAR.7-MI-INr hourly charges associated with this project <br /> or activity will be billed to me or my business as tifled on tE_ Hthis form, <br /> 1 also certify that I have prepared this applie on rid that the work to be performed Will be done in accordance with all SAN JOAprrl;v <br /> Col N i t' Ordinance C odea,5tandarde, ST L • d Fi7t)E L.laws. <br /> APPLICANT'S SIGNATUR-E: I),, rc- <br /> PROV HTt'i BUSINI,1,SOWNT1113 PE :i'3'l)R/ ANA(.'F.R ❑ OTHER AIJHORILEI)ACF.N7'❑ <br /> 1l:41'!°Lu'r.vt is tivi 1 eB Lt. -c P Rrr,proof of aulhori;alion to sign is required Title <br /> AUTHORIZATION TO RELE NFO ATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby autho a the release of any and all results, geotechnical data and/or environmental./site assessment <br /> infarniation to the SAN JOAQUIN COUNTY ENV1RONMENr:1L IIEAt.Tti DrPAR't'NJFNr 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: R-f-Vt irVJ 50t L <br /> COMMENTS: <br /> ACCEPTED BY.,, i EMPLOYEE#: C.., .:." DATE: 1 j <br /> ?r- / ! <br /> ASSIGNED TO: ::. - EMPLOYEE#: DATE. <br /> 41 -, / r )0 2 C. �{ <br /> Date Service Completed (if already4 ompieted). SERVICECODE: r- ._ ;r Pf E: <br /> Payment Date <br /> Fee Amount: �. Amount Paid y <br /> Payment Type Invoice# Check# Received By: <br /> E FID 48-02-026 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />