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JA-IN JOAQU1N k-OUNTY LNViRONMEN"i'ALUEALfti 1lEPARTMENI' <br /> �• SERVICE REQUEST _ <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -�M_0 0 3 0 S sl,-), <br /> OWNER PEJJRATOR ! jj�� CHECK If BILLING ADDRESSFq <br /> O C! TZ <br /> FACILITY NAME <br /> SITE ADDRESS � <br /> G ulZ(-) Street Number Direction I PZI CStreet Name t-ItAC Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> a:� 7 e G �C' Street Number Street Name <br /> CITY STATE ZIP <br /> I,,C�1���� y3-13 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQ UESTOR CHECK if BILLING ADDRESS E] <br /> :.a �vl SO•t/ �SOcf �� <br /> BUSINESS NAME PHONE# ExT. <br /> LO`! ?,( , - 1 701 <br /> HOME Or MAILING ADDRESS FAX# <br /> 2Z Nvv- fi�-, (2-017) 3-?3- V?0 3 <br /> CITY I CA STATE ZIP ?57 G <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 VIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business i entified on this form. <br /> I also certify that I have prepared this ap is tion and tha the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, T E and FE DE laws. <br /> 77APPLICANT'S SIGNATURE: -1-V DATE: �� 4 C' Z <br /> PROPERTY/BUSINESS OWNERO( OPE R/MANA R OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not 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 environmentaUsite 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: A d" n a s S <br /> COMMENTS: <br /> g 1 *&� � PAYMENT <br /> J p RECEIVED <br /> (v d AUG_14 2002 <br /> SAN JOAOUIN COUNTY <br /> APPROVED BY: EMPLOYEE#: � HEALTH l V <br /> ASSIGNED TO: 0-7 G EMPLOYEE#: DATE: <br /> Date Service Compl ed (if alreaa completed): SERVICE CODE: 5Z P/E: 6 L <br /> Fee Amount: 7 Amount Paid - Payment Date <br /> Z <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUESTpFORM <br /> REVISED 6-5-02 <br /> a9 <br />