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Utut JVN�VLl\ I.VUI\11L'L\V1n"INIV1G1\i AI,I1P.HL In"rrAK I IV1G1V1 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQ <br /> OWNEER/PERATOR , <br /> kK If LING ADDRESS <br /> FACILITY NAME <br /> E ADDRESS <br /> cL <br /> S et Number Dti / ��/ 0 <br /> Street Name Ci Zi ode <br /> ME Or MAILING DRESS (If Different from Site Address) <br /> Street Number <br /> Street Name <br /> CITY / ^ TATE IP <br /> PHONE#1 EXT. APN# ���/ao-ac�/JBOS <br /> AND USE APPLICATION# <br /> PHONE#2 ExT• DI //� LocanoN CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS. <br /> LL) E T� ASS0(LA q • iJC_ <br /> BUSINESS NAME PHONE If <br /> 205Szy - csl� <br /> HOME or MAILING ADDRESS 1 F� ) <br /> 5 2 /;+k s -c r_-F <br /> CITY ?-10 41C <br /> STATE C'j ZIP q 3 <br /> BILLING ACKNOWLEDGEMENT: 1, 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\�J <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this a, Ii and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S d FEDERAL Is <br /> APPLICANT'S SIGNATURE DATE: <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/ ANAGER OTHER AUTHORIZED AGENT-E] <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tire <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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> Cdxl�rso-, � ,�1 ��77 7cY- <br /> 4/olro gpmtn ) SAEN�IRONIMtlENl <br /> / TH pEPA <br /> ACCEP ED BY: EMPLOYEE#: ,frO DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already-completed): i 911y(o(, SERVILE CJOD/E:/�i0,0 PIEi ,;L,? <br /> Fee Amount: ���-� Amount Paid \ Payment Data l <br /> Payment Type Invoice# Check# 1y ` 2 Z Received By: <br /> EHD 48-02-025 SRFORM(Golden Rod) <br /> REVISED 11/17/2003 <br />