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J�11V JVA�Ul1V l-.VU1V11 L`1VV11iV1V1V1L'1V1t1L11L't1L1111JL'1"[11i11V1L'1V1 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Ll c�/t'1 <br /> Tl F ize/,A L T/Z A Z- /: <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> C'ALlcrn15 /Mj)usi9/ /Ae- /ACk <br /> SITE ADDRESS 161501 <br /> Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESSS�(If Different from Site Address) <br /> 2 l Y - ` Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> ( ) .-- 110.:�-, 1c/ _ - � , 6,P -(/-3 / ZR, - 9 3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> RECIUESTOR <br /> CHECK If BILLING ADDRESS V <br /> BUSINESS NAME PHONE# EXT.�, � �C� . <br /> HOME Or MAILING ADDRESS FAX# (c <br /> CITY T�KLOC/� STATE Zip <br /> ZIP <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 nle 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 FEDE L laws. f <br /> APPLICANT'S SIGNATURE: A DATE: / Z — � <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the Bli i c,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 OFSERVICEREOUESTED:///rl2tir,9- LOAD/DC7 /tN/-7 SCYL- SGl%rAr/� /� ST(�I� � <br /> COMMENTS: /O• IG-o'.L RFPbRT 1REVt6k*Zp�YM1�E© <br /> Olt 4�ECE <br /> /7,, o v p ', ��0©Z <br /> � n <br /> f SANJpAG1UIS RV1G�S <br /> N��HEAtZH DIv131nN <br /> APPROVED BY: / EMIL YEE#: C�Gj DATE: <br /> ASSIGNED TO: �A /i� EMPLOYEE#: 'j t�y / DATE: O L� <br /> Date Service Completed �if already completed): SERVICECoDE: — P/E:2 C� <br /> Fee Amount: �{� OG Amount Paid 9f(/ _ Payment Date <br /> ayment Type �/ Invoice fl Check# Received By: <br /> -01.025 SERVICE REQUEST FORM <br /> =D 6-5-02 <br /> Q <br />