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alk IN J"i1VU11N %,"UiN I Y i.1V V11[V1V1V1L'1V LHL 11L'HLl[1 1JL'1'H1(11V1Y:1V 1 <br /> %%PW SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 15k 00 3� 4 0-d <br /> OWNER/OPERATOR �j <br /> S"j�11 / ��,�/ ��7 I�� I,f-.l . l CHECK if BILLING ADDRESS LJ <br /> FACILITY NAME 1, /TT/4--C 1 i� <br /> SITE ADDRESS I CJ l `� !`� FEL i 1 E(Z R-P L,Q,u P o -i S'LZv <br /> Street Number Direction Street Name City ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) r� <br /> IIS -25 E Ib � RAA'; 1reZ-5 YC? Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT" APN# LAND USE APPLICATION# <br /> SSI - X233 rr--)-30 -iy <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �H c) CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME , PHONE# ExT. <br /> rte. <br /> 7��-�-►o� <br /> HOME Or MAILING ADDRESS FAX# <br /> Fo, ( Zc),j) -75"i <br /> CITY / 4,1L4V5 STATE /--,A ZIP 9-�;2-Z-Z -� <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 d FED7Z��, <br /> s. <br /> APPLICANT'S SIGNATURE: DATE: /0/0 <br /> PROPERTY/BUSINESS OWNER <br /> ❑ VPETOR/MANAGER El OTHER AUTHORIZED AGENT [3IfAPPLICANTisnottheC, <br /> PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INI+ORMATION: 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: llac& rU i I KAhft <br /> COMMENTS: <br /> VN <br /> APPROVED BY: EMPLOYEE#: 6� BATE: ' 2 Z <br /> ASSIGNED TO: r Q � EMPLOYEE#: 40 J 4iqq DATE: <br /> Date Service Completed if already completed): SERVICE CODE: P i E: <br /> Fee Amount: 1-7$ Amount Paid I�1 '�- Payment Date <br /> Payment TypeInvoice# Check# Received By: -��__ <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br /> ro <br />