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01VIN J UAVU11N 0U1N 1 Y JI✓1N V 11ZU1N1VlU' IN 1AU "r1 Al.l *LYH1t11vt E 1N 1 <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID #�\(� SERVICE REQUEST # <br />OWNER / OPERATOR / CHECK If BILLING ADDRESS❑ <br />0- 777 O V' 7'L 0. I) k & wz /� O I <br />FACILITY NAME v l <br />I,v D G CA- Y S <br />SITE ADDRESS 0 673 30 <br />St ee Number I Direction StrAN Ck <br />CI Ziu Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />CITY STATE ZIP <br />PHONE #1 ExT• APN # LAND USE APPLICATION # <br />(,267 ) 95 S - 7� G <br />PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />EQUESTOR <br />` �� �O r _[� e r CHECK If BILLING ADDRESS q <br />BUSINESS NAME .. J I/ PHONE # EXT. <br />/1 / 2 = Cr d 1V rV_ 0. C �O (;ZO lv j 3 <br />HOME or MAILING ADDRESS FAX # <br />S 7 w t 1,4/ 0. 77 2 P ( ) <br />CITY S /j` STATE �- ZIP q <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, STA and F DERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER ❑ leBILLING <br />ERATOR / MAN ❑ OTIIER AUT11ORIZED AGENT ^,Ll� � 5 5r. Aj � 9 <br />IfAPPLICANT is,to t 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 Ote 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: I S e C <br />0 S UJ T- Ft i h r� I` <br />COMMENTS: <br />PAYMENT <br />RECEIVED <br />Nov 4 8 2002 <br />SAN JOAQUIN COUf•; IY <br />PUBLIC HEALTH SERVICES <br />APPROVED BY: <br />EMPLOYEE #: j� Q <br />Y 1 <br />DATE. ✓ Q 'I/ <br />ASSIGNED TO: <br />EMPLOYEE #: , ,I; o <br />DATE: <br />Date Service Completed (if already completed): <br />777SERVICE <br />CODE: <br />C` <br />P / E: 2.3 0� <br />Fee Amount: -1-1(01-7 <br />Amount Paid <br />4 6 7- G 0 <br />Payment Date <br />Payment Type I/ <br />Invoice # <br />Check # �� Gi � <br />/' <br />Received By: <br />ey <br />EHD 48-01-026 SERVICE REQUEST FORM <br />REVISED 6-5-02 <br />rs <br />