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v�ur wWl %ZrfIt' l "Ul\1I L'11VIn"111VIV,111ALKA-VAL11Y11P.YAnIIV11S1`11 <br /> SERVICE--REQJEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> sRoa s 3939 <br /> OWNER/OPERATOR <br /> n / , ` /� n �na CHECK if BILLING ADDRESS <br /> V G <br /> FACIurY NAM l.r <br /> SITE ADDRESS <br /> 1 <br /> 77OO <br /> P� `/ Oa <br /> Street Number Direction SHeet Name city ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> COM M P/e p /, Street Number / Street Name <br /> CITY /v S i4 ATE ZIP <br /> [ a 5� <br /> PHONE#1 E'' APN# LAND USE APPLICATION# <br /> ( ) 6Z D O Z <br /> PHONE#2T• BOS DISTRICT LOCATION CODE <br /> ( ) G <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 61I & S P" , / CHECK If BILLING ADDRESS <br /> BUSINE'S'S NAME ( PHONE# En' <br /> r1 d 33,4-6 r-2.? <br /> HOME Or MAILING ADDRESS FAX# <br /> a- 4/, Oa C4, k- ? l 1 <br /> CITU / I; STATE ZIP : , /i O <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, 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,Standards,STATE ancil FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 0. --Lll DATE: �— <br /> PROPERTY/BUSINESS OWNER 11 0 0 OPERATOR/MA/ACER OTHER AUTHORIZED AGENT❑ <br /> 7fAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 environmentaVsite 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: I <br /> COMMENTS: <br /> RECEIVED <br /> -°g ya��, Npn 1 7 eub8 <br /> .S r ° 6� / .y> SAN JOAQUIN COUNTY <br /> th/•1/ ENVIRONMENTAL <br /> r HEALT <br /> ACCEPTED BY: (4017A EMPLOYEE#: 6 2i l -1 DATE: l Qg_ <br /> ASSIGNED TO: 1 1 EMPLOYEE#: S �\ DA7E: — I T� —Q,E <br /> Date Service Completed (if already completed): SERVICE CODE: 3 t5 PIE: ,)6 C) <br /> Fee Amount: °-= Amount Paid 1 `l i ,,� Payment Date L( <br /> Payment Type Invoice# Check# <br /> EHD 4&02-025 ``SR FORIvf( old2n Rod) ' <br /> REVISED 11/17/2003 <br />