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—V{ l I A 1 L1Ir1AL,JUVAL11111LI•YAXIAI ;NT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> 11 � �►� �V ` ` \ CHECK If BILLING ADDRESS L� <br /> FACILITY NAME <br /> l <br /> SITE ADDRESS <br /> Str1.1.-'OoDirectioneet ,--1,"W�-``• Street Name - � Cit 2i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• # <br /> LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICTLOCATION ODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR � � , <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME ,t� ^ PON LA �0 E" <br /> D. <br /> HOME Or MAILING ADDRESS F # ) L4 <br /> CITY STATE 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 /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: t, <br /> DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTH AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign;s require T;t;c <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: uS T'Qo-' � yME �O <br /> COMMENTS: <br /> N <br /> uN <br /> ACCEPTED BY: 1 U t EMPLOYEE#: Lr DATE: <br /> ASSIGNED TO: t ,t _ EMPLOYEE#: 70 DATE: 1 `� <br /> Date Service Completed (if already completed): SERVICE CODE: - P 1 E: 0� <br /> Fee Amount: ` -3 T�o L) Amount Paid 3 4 S � Payment Date <br /> Payment Type L--� Invoice# Check# S -2� Received By: <br /> EHD 48-02-025 SR FORM(U`old2n Rod)' <br /> REVISED 11/17/2003 - <br /> 1 <br />