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SERVICE REQUEST ,x! <br /> Type of'Susiness or Property FACILITY ID# SERVICE REQUEST# <br /> Re�stcleV) 1c91�LV005=040 - 5`&i(6k�`' I< . LLi <br /> OWNER/OPERATOR <br /> " CHECKNILLI <br /> BILLING ADnRE55O <br /> 11 kCYS M4 <br /> FACILITY NAME <br /> SITE ADDRESS 74 a <br /> ��r 11/ 15,2�-o <br /> Slreel umber Direction Street Name CI 21 Cade <br /> HOME Of MAILING ADDRESS (It Different from ELSite Add/less) <br /> 2-4. (Poe) /V, tale~o^e� `�-�n Street Number /7�.�CE(� Street Name <br /> CITY V �C / L Com/ / ZIP cj/ 3 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# b <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REOUESTOR CHECK it BILLING ADDRESS <br /> PHONE# Exr. <br /> BUSINESS NAME G fv i _l 3 <br /> HOME or MAILING ADDRESS FAz# <br /> U/ CI /-237 <br /> CITY / 0 ei I, <br /> ST ZIP 9s,1 <br /> BILLING ACKNOWLEDG MENT: 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,S'r43f,and FEDERAL IaWS- L,( <br /> APPLICANT'S SIGNATURE: zL DATE' <br /> PROPERTY/BUsINEss OWNER❑ OPERATOR/MANAGER ❑ ` OTHER AUTHORIZED AGENT ✓L L rL <br /> If APPLICANT is riot the BILLING PAR ry 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. C <br /> TYPE OF SERVICE REQUESTED: �t/ gyp'/ SO <br /> COMMENTS: i�0� RL- <br /> M J APR 16 <br /> EdViCI c <br /> APPROVED BY: EMPLOYEE#: L DATE: <br /> ASSIGNED TO: ,/ EMPLOYEE#: DATE: <br /> S Q (�vL <br /> Dale Service Completed (it already completed): SERVICE CODE: 2-Z PIE: <br /> ij <br /> Fee Amount: Amount Paid - Payment Date <br /> Payment Type Invoice# Check Al 3 Re eived By: <br /> SERVICE REQUEST FORM <br /> EHD 48-01-025 <br /> REVISED 6-5-02 <br />