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--- ----..�.,.•• •-,..va.aaa.a. ra1�v1�tv1G1V 1111,ElEAL111 1JEFAK11VIENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# jSERVICE REQUEST# <br /> OWNER/ OPERATOR <br /> V!My c Q CHECK if BILLING ADDRESS <br /> FACILITY NAME �..� <br /> SITE ADDRESS cJ U <br /> I e _ ^��a <br /> 1 r+�� Sl(, <br /> Street Numher Direction T ���:Yz�,,� J Zi Code <br /> HOME Or MAILING ADDRESS (If Different <br /> It �from <br /> _Site Address) <br /> w Y�-j— Street Number Street Name <br /> CIN ,C-N\ C STATE ZIP <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> ( ) 22-7— O?O 3/ <br /> PHONE#2 Ezr. BOS DISTRICT ♦ ! LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �� � ��•'-L-'(�( � CHECK if BILLING ADDRESS® <br /> BUSINESS NAME 6�l PHONE# Em <br /> �-\ ' •�- io 1 -1n 33�-- <br /> HOME or MAILING ADDRESSFAX# <br /> r ) <br /> CITY 1Ly1 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 FADE laws. <br /> APPLICANT'S SIGNATURE:�p � �J, DATE: <br /> PROPERTY/BUSINESS OWNER[I OPERATOR/MANAGER ❑. OTHER AUTHORIZED AGENTS <br /> -If APPLICANT isnot the BILLINGPARTP proof Of authorization to sign is required Titre <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: ! ,-T <br /> COMMENTS: <br /> VO o 28 ?449 <br /> ACCEPTED BY: OLt t ,Q tt EMPLOYEE 03 ZI 4,14 OG, <br /> ASSIGNED T0: N�'t i� EMPLOYEE#: 'Z v DATE: C� (J <br /> Date Service Completed (if already completed): SERVICE CODE: �Lt g PIE:z30� <br /> Fee Amount: 3 �, Amount Paid 3(5 Payment Date y/n 1041 <br /> Payment Type ,/ Invoice# Check# 14o 4zi Received By: <br /> EHD 48-02-025 ' SR T O"f (1a'oLd' n Rod)` ' <br /> REVISED 11/17/2003 -- - - <br />