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3AiN J6Al2U11N I,VUNI-Y hNVIHU1NiV1hN'I'AL11hAL'1'1-1VE.PAItlIV1C1N'l' ao0 <br /> SERVICE REQUEST _ <br /> I Type of Business or Propefty-'i FACILITY ID# SERVICE REQUEST V <br /> �1 t .niton Flo <br /> OWNER I OPE TOR <br /> CHECK 1fBILLING ADD RESS <br /> 1�4-T'62C L4JCI <br /> FACILITY NAME <br /> &- <br /> SITE ADDRESS l R gC-7 <br /> Street Number Direction Street Nam city Zlo Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) �✓ Oo y <br /> too Street Number Street Name <br /> CITY (� STATE zip <br /> S T' A SJ <br /> PHONE#1 Ex T. APN# LAND USE APPLICATION# <br /> ( ) ©`1.....p 0 - p . <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> ( } <br /> 4 11 <br /> CONTRACTOR! SERVICE REQUESTOR <br /> i REQUESTOR CC <br /> J !� ,5-9 <br /> c r CHECK If BILLING ADORESSW <br /> yallnolu R-) <br /> BUSINESS NAME 1 ) y J PHONE# EXT' <br /> rL,/ D6 <br /> HOME or MAILING ADDRESS FAK# <br /> I.D.- SyCV Z-k4AJ6 &t)L-)' f - 20 ) S-,26 <br /> CITY AT 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 HEALTti 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, TE a F13DERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I hIANAGER ❑. OTHER AUTHORTzED AGENT /4 Ll PMJAJ-Fi� g _ <br /> IfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHOR17ATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the prop Yl the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environrner>RrQt�e ent <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and a ftai1 f�ertit is <br /> provided to me or my representative. <br /> Uutt <br /> TYPE OF SERVICE REQUESTED: G SAN E 1VViRONNIF <br /> COMMENTS: -7''; <br /> Ns <br /> ACCEPTE=D BY: EMPLOYEE#: � DATE:r 1-7 O <br /> ASSIGNED TO: EMPLOYEE#: 11 DATE <br /> MlepyklAf <br /> IT <br /> Date Service Completed (if already completed): SERVICE CODE:: P 1 E <br /> Fee Amount: Amount Paid O s Payment Data <br /> Payment Type invoice# Check# 2 Z Received By: <br /> EHD /y rr�-�1 iSR1Qll+!t `blden'Rrid) <br /> REVISED i0 1712003 `�` ti-/ '=� <br />