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SAN JOAQUI100 UNTY ENVIRONMENTAL HEALTIOEPARTMENT <br /> e <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> IE SA0033 - 1+ ? <br /> OWNER/OPERATOR �I Iq <br /> bou) 1q) I�e� Q Y CHECK If BILLING ADDRESS El <br /> FACILITY NAME l 1 J V [' (� <br /> SITE ADDRESS 16 ( IYC\/\SPOI�IQ CCI"\ ��' {-'•'(vcvV \B� <br /> Slrecl Numher Direction Street Name Cit Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 301 ` I <br /> Street Number reef Name <br /> CITY J�\ STATEZIP [' / <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> I 14 ao 33 - i A La 3 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) �_A0 end <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRtSS <br /> �- <br /> BUSINESS NAME PHONE# EXT. <br /> a ut, do 6 7 76/ <br /> HOME or MAILING ADDRESS FAIT# <br /> ( o5 ) 333 -�- 3 <br /> CITY t IL1 Cl L/!^1 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 HEALTI'I 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,Stonelord• STATE annd�FFfDERAL laws. (� <br /> APPLICANT'S SIGNATUR� j_ n DATE: <br /> PROPERTY/BUSINESS OWN ER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGF-N4Q'62 &V� <br /> /f APPLICANT is not lite BILLING PARTY proof of authorization to sign is required PRIM ENT <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the 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 ar%gfi , 0iJ6BI3 it is <br /> provided to me or my representative. n r <br /> SAN JOAOUIN <br /> TYPE OF SERVICE REQUESTED: .y�� b4 1 r� ,y P"",4EALTH SFRVICESI <br /> COMMENTS: PI'QLrI�1 l iJ0A,' �L_ ���C�(i1 ' V(,(, ' �V'J QlM�f UCvt S 1 — e OLD <br /> I�Qteffle(ct���/d Ivdu� bvi 367-3701 . (�cfLVi�Ji cGPc✓tiC� <br /> 171, <br /> oy <br /> APPROVED BY: EMPLOYEE#: `�'Z L DATE: 'PA -63 <br /> 3 <br /> ASSIGNED TO: EMPLOYEE M *� �' l DATE: 8 0 <br /> Date Service Completed (if (ready co pleted): SERVICE CODE: (3Z T 131E: 21pQZ <br /> Fee Amount: 9 4r Amount Paid 0,(f s` Payment Date 03 <br /> Payment Type Invoice If Check# j�.q a-� Received By: 10 <br /> EHD 25 �/ tj R `r 3 / NICE REQUEST FORM <br /> REVISEDSED 6-6-5-02 OL+�iI-°•t.W ""� 0"16 ✓rvYlra� WW <br />