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SAN JOAQ000UNTY ENVIRONMENTAL HEA* DEPARTMENT /� <br /> SERVICE REQUEST /lMY//) <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> UTILITY nbb39�� 5 t20--W &' <br /> OWNER I OPERATOR CHECK If BILLING ADDRESS❑ <br /> (QAC/FIG S �[—EcT2/L N <br /> FACILITY NAME <br /> T/2,eA 5 s`/5�M I✓I A/itr/s�./r/AN S TE3+/ <br /> SITE ADORESSZ/,,O S; .5 Me <br /> TA <br /> r Street Number Direction Street Name Cil Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) //JJ�� <br /> ATV /r Street Number ea-m€— <br /> CITY /J STATE ZIP'�;V!S7,9 <br /> PHONE#1 L Exr. ApN# LAND USE APPLICATION# <br /> PHONE#2 EXI. BOS DISTRICT LOCATION CODE <br /> 61 ) <br /> CONTRACTOR / SERVICE RE' QUESTOR <br /> REQUESTOR — <br /> Y��e (A./c A/ElL , /E♦<LY Q,(� A CHECK If BILLING ADDRESS� <br /> BUSINESS NAME 1. r PHONE# EM <br /> HOME or MAILING ADDRESS FAx# <br /> G /EsrN,q- Ave- . (sro Z&8 - 354.4 <br /> CITY /� STATE C'4 ZIP 3 2z5 <br /> BILLING ACCrKNNOWLF.DGF,MENT: 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 FE i s. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPER Olt/MANACFi ❑ DTIIFIt AUTIIDItIZFD AGENT❑ <br /> /fel PPLIC'ANT is not the DILLIN T AGO <br /> of authorization to sign is required Title <br /> AUTIIORIZA,rION 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 /> infolnwtioh t0 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. D <br /> TYPE OF SERVICE REQUESTED: % �VE <br /> COMMENTS: VI/ / -57— r- MOVA' 30"% % 2V <br /> UN <br /> SAN OAQUIN S RV pE <br /> PUBSIONO ENTA�THEAITH <br /> ENVIPONM <br /> APPROVED BY: EMPLOYEE#: DATE: D 2 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O P 1 E: <br /> Fee Amount: Amount Paid Op �-D I Payment Date <br /> Payment Type ✓ Invoice # Check# 5,73 So Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />