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SAN <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # SERVICE QUEST # <br />CHECK If BILLING ADDRESS <br />a20ey <br />OWNER /OPERATOR <br />CICK If ALUNaARRB=0 <br />FACILITY NAME <br />Ty-azq <br />HOME or MAILING ADDR S <br />G <br />SITE ADDRESS I <br />i zi-T—rv-6-t� <br />FAx # <br />(,q IF') <br />-BUJCL <br />L 4 <br />1 <br />STATE d4 <br />Street Number <br />Date Service Completed (if already completed): <br />treat Name <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Amount Paid <br />/ <br />Paymert Date <br />Street Number <br />Street Name <br />CITY <br />STAY Zip <br />PHONE #1 Ext. <br />0eq) <br />APN #/ <br />L D USE APPLICATION <br />PHONE #2 Exr. • <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRAMOR / S'7�.r,,EQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAMEP <br />COMMENTS: <br />r. it <br />(Z'�) <br />EXT. <br />aA (ao3 q <br />HOME or MAILING ADDR S <br />G <br />EMPLOYE <br />FAx # <br />(,q IF') <br />c� 1 166 - <br />CITY C <br />STATE d4 <br />ZIP I <br />acknowledge that all site and/or proN <br />or activity will be billed to me or my <br />I also certify that I have prevared this <br />COUNTY Ordinance Codes, -S-0-n2laiV. <br />El 2 2 11 F!'y 111 " 4 of <br />PROPERTY / BUSINESS OWNER13 <br />If APPLICANT is not the <br />1: 1, the �dersi ed perty or business owner, operator or authorized agent of same, <br />de <br />rs' ed p <br />Nv'RONM T' <br />tj <br />W1 e <br />' ' t"*4 <br />�ct specific ENVIRONM TAL HEALTH DEPARTMENT hourly charges associated with this project <br />' I <br />siness as identifie on this form. <br />app tion and t t the work to be performed will be done in accordance with all SAN JOAQUIN <br />c <br />FE RAL laws. <br />DATE: 414accl <br />OPERATO MANAGER 0 OTHER AUTHORIZED AGENT P 01n- (i -(,o LL�CLO <br />BILLIN. IPURP TY. proof of authorization to sign is required 14 Title <br />AUI-HORIZATIUN TO RELEASE INF RATION: When applicable, 1, the owner or operator of the property located at the <br />above site address, hereby authorize t release of any and all results, geotechnical data and/or environmental/site assessment <br />I <br />information to the SAN JOAQUIN COU/NENVIRONMENTAL 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: W Ae-QACC CA <br />'YA4Pr\, <br />COMMENTS: <br />W/o <br />APR 3 2%9 <br />SANJ0AQ0 <br />ENVIRON"'- UI'JT-y <br />H MEN7-A; <br />EALTH DEPAriT7V1L-N7- <br />ACCEPTED BY: <br />EMPLOYE <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE <br />DAM: <br />Date Service Completed (if already completed): <br />I SERVICE CODE: <br />P E <br />t j� <br />Fee Amount: <br />Amount Paid <br />- <br />Paymert Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />