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'!)AIN JOAQUIIN %,OUINI Y L'N VIKON1VILIN IAL"EALI II m'VAKIIVIuN l <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ OPERATOR <br /> CHECK if BILLING ADDRESS L <br /> F/ 7 <br /> CILITY NAME <br /> E DRESS ;� / / 9 ��� Q �ZZO <br /> "' Street Number Direction ,V ' /Street✓Nam/e Cit /�/Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 1 1591 <br /> / Street Number <br /> CITY'0'q'-' <br /> Street Name <br /> r0 STATE -� ZIP <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# / <br /> ) 4S - -Z61 z7 19,13 - -Z-Z0-/6 P4 tn�5 <br /> PHO E#2 EXT. BOS QJ$T ICT ] LOCATION CODE <br /> qq <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR � r1�-r1 <br /> �e�/i� S� � CHECK if BILLING ADDRESS 1_7 <br /> BUSINESS NAME ' ` PHONE# EXT. <br /> HOME-ZMAILING ADDRESS cy/c, /, lJ/ �� _ '/' ) -3:3 J — -Z-&/r <br /> CITY - Q .J/ C!/ -/- STATE .(--4 ZIP Tc-) 5C�2- 4-0 <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 HEALT-I 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: <br /> DATE: <br /> PROPERTY/BUSINESS OWNER❑ O ERATOR/MANAGER ❑ 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 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: c A, 1AC PAYMENT <br /> COMMENTS: R E <br /> MAY 1 0 2007 <br /> SANMAROON N COUNTY <br /> ENVIRONMENTAL <br /> HEALTH nEPARTMENT <br /> APPROVED BY: EMPLOYEE M DATE: n <br /> ASSIGNED TO: S s G` r�n r ., EMPLOYEE#: G, /_ / DATE: <br /> Date Service Completed (if already�c-o�mpleted): SERV`I•CEE CODE: <br /> O l0� PIE: <br /> 1E: <br /> I <br /> Fee Amount: , I of �`� Amount Paid fc1 Payment Date S L> 6 <br /> Payment Type Invoice# Check# 3 ��y Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />