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JAN JUAljU1N L.UUN I LIN VIKUNIVIEN'I AL nEAL'1'H LEYARI MEN 1' <br /> SERVICE REQUEST <br /> Ty p f Busina or Property FACILITY ID# FA0033+ 1 ­7 <br /> ERVICE REQUEST# <br /> r' d0 3 4 q <br /> OWN 1 nPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> LI f fl *n f)fN- ��I(� <br /> L41LI Street Number Direction I• I Sttreet Name VCi 1 0 1 ZI Cotle <br /> HOME Or MAILI ADDRESS (If Different from Site Address) <br /> bauStreet Number Street Name <br /> CITY TATE ZIP <br /> Ind C�. c45 - <br /> PHONE#t ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 EaT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR - <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME �( f,h-� ,�) n p PHONE# I„ � f _ bq Exr. <br /> HOME Or MAILING AD RES��� ' f t (�l!�(J e�f FA%# ) +( I'_`L�34gz <br /> CITY d w STATE ZIP (moi L, <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> icknowledge 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, S DAL laws. <br /> /APPLICANT'S SIGNATURE: U �(y <br /> DATE. <br /> �/ Q / }/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT LJ V .�PJZ( � z M1' Tadd v <br /> V'APPI/CANT is not the BILLING 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 site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaVsite 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 r�i"r� i f' PAYMENT <br /> COMMENTS: <br /> APR - 9 2003 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPROVED BY: EMPLOYEE M Z-L ,t DATE: _ <br /> ASSIGNED TO: EMPLOYEE M -7 3 DATE: 4 -9 -3—L -9 •- <br /> ✓ <br /> Date Service Completed (if a early completed): SERVICE CODE: IPIE: '13q <br /> Fee Amount: 1(0 1 Amount Paid Payment Date It _e`, D--3 <br /> Payment Type Invoice# Check# - Received By: k�' <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 ,� <br />