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0A1V J VAl1UIiN x- ')IN 11 C lV V IKVINIVIL'1V I/1L A=AL1It J ILL I-PVICI INIL'iV I <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 11 <br /> OWNER/OPERATOR <br /> OY O O CHECK If BILLING ADDRESS <br /> FACILITY NAME (..' <br /> SITE ADDRESS <br /> Street Number Dire. Z tr �Q/ Z7�otle I <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#t ExT. APN# LAND USE APPLICATION# <br /> ( ) 1 005 ® 5 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REOUESTOR <br /> / oe//A� Nle A, CHECK If BILLING ADDRESS <br /> / <br /> BUSINESS NAME r / r PAIL 2 HO Ex <br /> r, <br /> # E' <br /> i / 33¢- 6523 <br /> HOME or MAILING ADDRESS FAX# <br /> z S � Z- <br /> V-01 ) 334-- <br /> CITY / O _// STATEC ZIP <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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: /O O/ O Z <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGEN'rr�I�, <br /> If APPLICANT is Not the BILLING PARTY proof of authorization to sign is requited 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 t0 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: <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVED <br /> OCT - 1ZM2 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> APPROVED BY: EMPLOYEE#: '- V_ .r'9.. <br /> ASSIGNED TO: EMPLOYEE#: ®e �'I DATE: _ —.- <br /> Date Service Complete (if alrea" completed): SERVICE CODE: 3155 <br /> P/E: -2W <br /> Fee Amount: '�� Amount Paid Payment Date <br /> Payment Type Invoice If Check# Received Ely: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br /> rs <br />