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J,I IN ,J%)AVU I IN '—"L'INI I VINYIIt"ININIGLvIll L 11G1lL ltl L1'.1'EV Ic 11VIL'Iv1 <br /> SERVICE-E,QUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SR004174S' <br /> OWNER/OPERATOR////77'' <br /> LJC✓'Q IC1 u(/I t� CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 138 N . t ,r /� C Ne� R �f� � ✓� 95Z 15 <br /> Street Number Direction V Y Street Name CI ✓ZI CoOe <br /> HOME or MAILING ADDRESS If Different from Site Address) <br /> 3 3 Street Number Street Name <br /> CITY I O STATE CA— ZIP 9 S� `CJ E3 <br /> PHONE#I `T En. APN k LAND USE APPLICATION# J <br /> ( ) (o 5 - 39 5S oZo -2S A' -6 - 6X7 eo� <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR A/�O/n el <br /> Se/ b <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME . EXT. <br /> Z—c" Sur v 69 334— �o5Z3 <br /> HOME Or MAILING ADDRESS FAX# <br /> k 5 S eZ (zp ) 334- z& I <br /> CITY / J i STATE ZIP 5-Z-4 C <br /> BILLING ACKNOWLEDGEMENT: 1, 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,Standards,STATE a EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: /t— 31 — 0 <br /> PROPERTY/BUSINESS OWNER❑ O ERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT qI /"TT n c, <br /> /f APPLICANT is not the BILLING PARTY proof of authorization to.sign is required I 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 /> e' TYPE OF SERVICE REQUESTED: <br /> COMMENTS: �EC'EIVED <br /> t <br /> n0`� MAR 3 1 2005 <br /> ry.24 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVEDB EMPLOYEE#: M�T DATE: 32 <br /> ASSIGNED TO: EMPLOYEE#: DATE: J <br /> Date Service Completed (if already completed): SERVICECODE: 15 <br /> P/E: 03 <br /> Fee Amount: Amount Paid a D -0 1 Payment Date 3/31 (os— <br /> Payment <br /> Os— <br /> Payment Type ✓ Invoice# Check# /9i, Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br /> n <br />