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0AIN JVAVU11V l.VU1V1I I INVIICVINIVIL'1V1ALIIL'ALlr1 LL'YAKJ1V1L'INI <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID If SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK If BILLING ADDRESSt'�Kt' <br /> GZ ITS fAM'ST�CIGT(c�G CAME�hG.Y ((( <br /> FACILITY NAME w ` , ,( Q`(e—�P—s mo <br /> SITE ADDRESS (Qin OCA 1 -S <br /> Street Number Direcibn am Zip e ' <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Nam <br /> CIT' STATE ZIP <br /> PHONE#1 EXT. APN# LAND USEL ATION# <br /> (201) g82 -47SO� (93 - 27 - 3 al -c2Sr <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR ` _ ^r <br /> CHECK IT BILLING ADDRESS <br /> BUSINESS NAME PHONE# En. <br /> IAKAA &.1(01 2A (ZkxiS 0 - Zos <br /> HOME or MAILING ADDRESS FAX# <br /> 73 11 Z1KaENdA\/fft4 DF, Sid ITE 16to 616 )4-Zt - 1700 <br /> CITY C A / !J A LAt_t t C© STATE �A 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 d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ���/ t, �— DAT�E� o <br /> PROPERTY/BUSINESS OWNER 0 OPERA7DR/MANAGER ❑ OTHER AunIORIZED AGENTpI <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign U 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it i vai`able and t the same timcfit IS <br /> • provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: I C�)UE❑ <br /> Soil SU��alo� <br /> dim r7 SA OA IH 0 <br /> K ONMF�L E310N <br /> APPROVED BY: L � OYEE#:eA - ' DATE: <br /> ASSIGNED TO: �_ lner /�A /`�� EM OYEE#: S3&C' DATE: <br /> Date Service Completed (if already completed): SERVICECODE: 52,T <br /> Fee Amount: SOo Amount PaidSOo Payment Date D 3 (��— <br /> Payment Type v Invoice# Check# �5 - Received B • ,e— <br /> EHD 48-01-025 SE�SJICE REQUEST FORM <br /> REVISED 6-5-02 <br /> 0i <br /> ijv-'T " <br />