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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTI-1 DEPARTMENT <br /> SERVICE REQUEST -.-- <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ,o 0,0 335--a-4 <br /> OWNER/OPERATOR f.✓e 3 v <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME / <br /> SITE ADDRESS <br /> SToC-,t-t <br /> Street Number Direction Street Naine Cit Zin Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> CITY C v p f c< G t'v c_( <br /> ,p_ Street Number Street Name <br /> S70 GLA-C- ✓ STATE ZIP <br /> CfA 4',--2( 9 <br /> PHONE#1 EXT. APN# //-02O— Z7 LAND USE APPLICATION# <br /> (20ct) 601-47222 //1 -020— Zq <br /> PIIONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> RECIUESTOR <br /> Q/4-(.) 7-1 Q ho ( CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT. <br /> 7-Lo 5 (4 �ci�d�O 2c 20 <br /> HOME or MAILING ADDRESS FAX# <br /> �'2GY /30..,�(� Cveu-c c <<.. <br /> CITY rSTATE CA J 2 <br /> 7 o c' c.r-Cv tJ <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned properly or business owner, operator or authorized :rent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HGAUI'l 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 clone in accordance with all SAN JOAQUIN <br /> COUN'T'Y Ordinance Codes,S/andards,STATE EDERAI.laws. <br /> APPLICANT'S SIGNATURE: n DA,rE: <br /> PROPERTY/BUSINESS OWN END OPERATOR/MANAGER ❑ OTHritAU'rimitizEDACENT, " Cp,(rTtin� �uti <br /> 1f APPLICANT is not the BILLING PAR:1-Y,proof of authorization to sign is requirl r1 � Tide <br /> AUTIlOR17.ATION TO RELEASE INF'ORMATION: When applicable, 1, 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 ENVIRONMGNTAI.III Aum DEPAR'FMEN T'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: L� - <br /> COMMENTS: RECENED <br /> 1xf ,Iiip <br /> APR 1. ,8 _003 <br /> � 5AN Ji )._ - <br /> �' <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: �} ( EMPLOYEE#: ',/TT�'�(((� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PI E: h2 <br /> Fee Arnount - 7 Amount Paid / `7 - -_ Payment Date J-/_/,3 - <br /> Payment Type [. Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> RFVISED 6-5-02 <br />