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„ ruv v VrL�Udiv �V UlV 1 Y L'lV Vll<V1ViVl1.IN lAL 11LALl I)EPAltlAIEN•l <br /> SERVICE REQUEST <br /> Type of Business or Property �tl r, FACILITY ID# f SERVICE REQUEST# r ', <br /> C- \• 0 X'Y-\ <br /> � Tx-,\- C1r� •`•f• ,rf�����...• �~���YDS i�.�y s 1' ��4� �� �'`�'��.., '���`{t <br /> O)g1NER/OPERATOR <br /> lam` n c)C_ © 1 t _ S CHECK if BILLING ADDRESS❑ <br /> _ FACtIITY NAME <br /> SITE ADDRESSR N61 t� <br /> Stree[Number Direc I n Sir,a Name cityZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) ”] l <br /> 1 "1 <br /> Street Number Stree RJa e <br /> CITY STATE ZIP O-� _ <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# I U I <br /> d0ri) L-4 1,S _'2 2 <br /> PHONE#2 ExT• BOS DISTRICT'T�" ` " ✓'° L' 6-"'C r <br /> 600 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR,;.-_ CHECK If BILLING ADDRESS <br /> BUSINESS NAME NONE# Ex1r• ' <br /> E\ Q_ uO C`C_v o r T n LI 61 <br /> HOME or MAILING ADDRESS �. WF #� r` ) X16 <br /> CITY ` STATE OCk 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 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 /> UNTY Ordinance Codes,StaYne <br /> TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE �SiSL DATE:PROPERTY/BUsiNESs OWNER❑ ATOR/MANAGER ❑ OTiIER AUTiioRIZED ACEw;pIf APPL1CiNT isING 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:• �cS 7� <br /> COMMENTS: <br /> 0 <br /> FNS\R • <br /> APPROVED BY: - EMPLOYEES k DATE <br /> ASSIGNED TO: EMPLOYEE# 3 DATE ..t s sr <br /> t N <br /> Dato Service Completed (if already completed) <br /> Feo'Amount: pL <br /> ( � Amount Paid .:���.;`• � Payment Date <br /> Payment Type Invoice# ' Check# s Ret eIved By. <br /> EHD 48-01-025 SERVICE REQU$OT FORM <br /> REVISED 6;5-02 \ <br />