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• �HiV J VH11U11V t.V U1V 1 Y L1V V1KU1V1V1L1�1'lAL t1L+'A1:1')Fi 1l�:YAlt"1.1ti1Li�'1' <br /> SERVICE REQUEST <br /> Type of Business or Property ,v +'FACILITYiD# SERVICE REQUEST <br /> UE <br /> i..•. t :.a. �. .. 4 7:n` '4' Yl.�� h�Ly1Y,1�.f <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS❑ <br /> kcv R20-Z)V C-c Ce m <br /> FACILITY NAME <br /> WE ADDRESS 2 0 W. ��Rwllnl .+1ol.T `J2 �f(� j-�-oC-,� UA( <br /> a. <br /> Street Number Direction Street Name city Zin Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) / CCI�T�YL�O I�-r� ��L1 lie <br /> 'i <br /> Street Number Street a e <br /> CITY 1.___0% STATE ZIP <br /> - � <br /> PHONE#'l ExT• APN# LAND USE APPLICATION# <br /> 00 -5300 <br /> .r <br /> PHONE#T ExT• BOS DISTRIC�,yTS `�t xtra ��� ,• LOCATIO�N+CODE y <br /> ( ) �:)•f'•4'b I�p'1'C.' �::L <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADORES <br /> BUSINESS NAME PHONE# T <br /> �14e�-wo tisS 1,rL ,.: to zji 54f1-f3/0 r67 <br /> ' <br /> HOMEforMa GADDRESS FAX#'.o , ;K k4 (zel 5q 7- 3/Z <br /> CITY �0 STT L <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 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$IGNATURE: DATE: 9 �,F LO Z <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT 4W-- n 1),'J <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:• f�lC2T (I��e!?Ei✓� L �j ic— <br /> �- <br /> COMMENTS: PAY�EN'r . <br /> REc�tvED <br /> ` - • - cEP � X2442 <br /> a UIN COUNT <br /> S gU�NEA�SH P R��VI10N <br /> APPROVED BY EMPLOYEE# C3�i{LR <br /> DATE: <br /> ASSIGNED TOEMPLOYEE <br /> 1 # DATE: <br /> Date Service Completed (if already completed): SERVICE CODE 7 P i E: <br /> Fee Amount: Amount Paid Payment Date , y;t 4 , <br /> Payment Type Invoice V Check# 2 Recelded By:".. '- <br /> l <br /> EHD 48-01-025 RVICE REQUriu FORM <br /> REVISED 6;5-02 ",-t , <br /> M v <br />