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-- .,. . ._ 1-1-1—il 1IAl,11V H1_,IT1 l.JEFAltI MINT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ERVICE REQUEST# <br /> __1!3P,00 <br /> OWNER IOPERATOR <br /> FACILITY DAME <br /> CHECK If BILLING ADDRESS <br /> � <br /> SITE ADDRESS ?�y0 <br /> Street Number Olrection 1 Street Name <br /> DOME or MAILING ADDRESS (If Different from Site Address) cityZi Code <br /> Street Number Street Namo <br /> CITY <br /> E zip <br /> PHONE#1 EXT. CPN#'�M LAND USE APPLICATION# <br /> PHONE#2 ExT. <br /> ( ) BOS DISTRICT LacAnoN CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQEIi:STOR -_ <br /> 4 l +•-�� <br /> CHECK if$ILLlNG ADDRESS / <br /> BUSINESS NAME - P NE <br /> HOME of MAILING,ADDRESS ) L4(01 <br /> FAX# <br /> CITYYA <br /> STATE ,zip <br /> BILLING ACKNC3WLEDGEIVIENT: 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: ~ <br /> DATE: <br /> � <br /> PROPERTY/BUslmrss OWNF: D OIPElZATOR/MAINACER D Or R AUTHORIZED AGEINT❑ <br /> IfAPPLIC.4NT is not theBILI,INILI,1 GPARgy proof of authorization to sign is required ZiZaa <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 environmentallsite assessment <br /> information to the SAN 7OAQUIN COUNTY EwRQNMENTA.L HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> piovided to me or my representative. <br /> TYPE OF:SERVICE REQUESTED: <br /> YF <br /> CEID <br /> 66MMENTS: ,66J��pD <br /> 192009. <br /> SANJOA-' -- - --- .... QtJlly cOt11y <br /> ;CLrr <br /> ACCEPTED BY: <br /> EMPLOYEE <br /> ASSIGNED70'" EMPLOYEE ff: <br /> 2— DATE: <br /> Date Service Completed (if already completed): SErevicE CODE' C <br /> Fee Amount. Amoun aid Payment Date !y Q <br /> Payment Type (i Invoice# Check# R 7 1 <br /> eceived[By: <br /> EI"ID 4M2-025 <br /> REVISED 11117/2003 :S FQF {Gbldl r<'=_Rad)` <br />