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SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID ID # <br />SERVICE REQUESTr#,, <br />OWNER i OPERATOR <br />J <br />CHECK if BILLING ADDRESS❑ <br />FACILITY DAME I\n I Q U 4 (Z .� <br />--A <br />SITE ADDRESS <br />Street Number <br />Direction <br />W���Street Name <br />FAX # 1 _ <br />� 10 <br />Ct Tlq Zip Qode <br />HOME or MAILING ADDRESS (If Different from Site Address)Ptd. <br />t Street Number <br />�� Street Name <br />CITYSTATE LP <br />6 -3 <br />PHONE #1 EXT. <br />I?c>q) f!-7`7 7353 <br />APN # <br />EMPLOYEE M <br />LAND USE APPLICATION # <br />PHONE #2 Err. <br />( 1 <br />ASSIGNED TO: �G� ' -- <br />'BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR. <br />REQU ST Rt <br />esj <br />CHECK If BILLING ADDRESS <br />BUSINESS �j <br />COMMENTS: <br />IL <br />PHONE Exr. <br />i <br />(_ r ✓ r3 <br />1' <br />-mss <br />HOME or MAILING ADDRESS r <br />ZZZ Gehl moi f CO v►�i <br />r <br />FAX # 1 _ <br />CITY Cly <br />STATE Cfi` ZIP475 ?,P1 <br />BILLING ACKNOWLEDGEMENT: 1, 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 <br />or 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: DATE:, L 2� <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <br />If APPLicANT is not the BILLING PART) ; proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 environmentaYsite 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 />nrovided to me or my reDresentative. <br />TYPE OF SERVICE REQUESTED: <br />L <br />COMMENTS: <br />IL <br />- <br />1' <br />SRdp <br />y�iTy,DFpMFiyoU <br />SRT �C <br />ACCEPTED BY: CA <br />EMPLOYEE M <br />DATE: LA - `�� • I� <br />ASSIGNED TO: �G� ' -- <br />EMPLOYEE <br />DATE: <br />Date Service Completed (If already completed): <br />SERVICE CODE: r� <br />P 1 E:lie <br />Fee Amount: 1 <br />Amount Pal/ <br />7 v 2) <br />Payment Date <br />Payment Type —invoice <br /># <br />Check .# G{-�g. <br />Recei ed By: <br />FA <br />