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i �.. a7Hly �JtJtlllVlir ti, 'iV A Y 1G1V V AA�VlV1VAl'_.1V AEAA.�A:Ef,A.,AAY ' 1',H,ACA 1vA1_'.lr A <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> OWNER/OPERATOR <br /> . relav1w ` /� �J� CHECK ifBILLINGADDRESS❑ <br /> FAcitrrr NAME /'� �l (� <br /> swnt Number INFectlon <br /> How or'MAILING ADOREsS (if Different from Site Address) � � Ala.$h�h f <br /> U Street Number t Name <br /> CITY � `� $TaTE� ZIP ���✓ <br /> PHONE#1 APN# LAND 7�_'OV6;' <br /> PHONE#2 EXT. BOS DISTINCT AnIoN 6DE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTORZ�-ar4 e-51 17� <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME41�—'/I/tL �,�� -31-1375# -1 3 <br /> G <br /> ROME or MA}LING ADDRESS FAX# �7 <br /> ,--5-3 ��s /a IN/ a /Fee/ . ( ) 4-3(— G <br /> CITY Gk STATE G/Q ZIP 01 <br /> 5.7 t!,;— <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 me or my business as identified on this form. <br /> I also c�rtify 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: - DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AuruoRIZED AGENrg_ <br /> If A'f'PaCANT is not the BiLuNG PARS proof of authorization to sign is required!! �` Title <br /> AUTHORIZATION TO RELEASE INFQRMATION: 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 SEAvicE REQUESTED: �u� >5d rJiZ fl' s7�/ PR`I'ME <br /> COMMENTS: /' � 7 <br /> '� /,/ <br /> �p1 Tr7i .. / c -'T ��` a� �'r✓ ,N SOA°u►N Coto <br /> pig <br /> f <br /> 3 <br /> APPROVED BY: EMPLOYEE#: Q DATE: <br /> ASSIGNED TO: EMPLOYEE#: �3 GtS DATE: <br /> Hate Service Completed (If already completed): SERVICE CODE: <br /> Fee Amount: (% 00 Amount Paid t ' '' Payment Date - r- <br /> Payment Type y Invoice# Check# Received By: <br />