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3AfN J VAVUIIN ()U1N 1 V EIN VIKVINIVIhIN I AL nEAL UH 1 AK l IVILIN I <br /> SERVICE REQUEST <, <br /> VFACIUTY <br /> ess or Property FACILITY ID# SERVICE REQUEST# <br /> �� � � zERATOR ICCHECK if BILLING ADDRESSCl/O <br /> T9S�Z Q <br /> Street Number Direction Street Name <br /> CiZi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> d S �GV Street Number <br /> CITY Street Name <br /> C+G�Gr� d STATE zip <br /> PHONE#1 EXT. APN# LAND US )PICATIO # <br /> 7 T-- In '-�L- (I <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR .y <br /> �, 1 aCHECK if BILLING ADDRESS C� <br /> BUSINESS NAMEPHONE# EXT. <br /> w LohsfrgJ' `� Iia 3 Z3 <br /> HOME or MAILING ADDRESS n FAX# <br /> CITY C�Iv, STATE ZIP (j <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,Standar- TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATA;: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGFR ❑ OTHER AUTHORIZED AGENT ❑ ' <br /> If APPLICANT isnot the BILLING PARTY,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. <br /> TYPE OF SERVICE REQUESTED: Askod wt4 i (h CEIVE� <br /> COMMENTS: m-, 3 r7 3 BAR 4 2003 <br /> - u1N GO011 <br /> l+►)� SANALSH SERVICES <br /> Q <br /> �� , .y�y�- P11 NMENTpt NEA�TN OIVISIQN <br /> 60 NN <br /> APPROVED BY: EMPLOYEE#: LZ�( L DATE: 3 --Lt i 3 <br /> ASSIGNED TO: T T EMPLOYEE#: r� DATE: ✓ ��j <br /> Date Service Completed (if already completed): SERVICE CODE: Z?i P 1 E: -2.6 o <br /> Fee Amount: ° Amount Paid �k> Payment Date <br /> Payment Typee# Check# L Received By: <br /> InvoicIt Z� <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />