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. •""` 01/�11f+' � �.Vu1v1k11,LNVIIiUIN04LIN1A.LAAI!,A Il UL1'Al(1'1V1L(V1 <br /> �.. SERVICE REQUEST 1 <br /> Type of Business or Property, r�rkt:( ;iACILITY <br /> .. t'>�.•.SERVICE REQUEST.'#'13„O,(.��+ t !,, <br /> 'Home s0-e �� 0031 S <br /> { •i OWNKR I OPERATOR <br /> vy� CHECKI(DILUNOADDRESSE] <br /> FACa.nYNAME ' <br /> 1 <br /> SITE ADDRESS <br /> r ,r <br /> 22- C- treetNmba .. .... ...UQ�Q-k .T ..T\C7 .. 7TC Ctl�p.0 . . Zip. 1522p .•l. <br /> HOME Or MAILINGADDRESS (If Different from Site Address) city <br /> i.- Crtr _ Slrse Ger <br /> ' - STATE ZIP <br /> PHONE#t Ezr• APN If, LAND USypP LIICCATIOH# <br /> PHoxe#1 6 BOSDISTRICL�11 'i+"•^ SLaC4'n6N''COa�} ]tfr <br /> ( ) I . <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> =Z-gt _ _ ytt}.-�,. CHEcKIfBRLiNoADaREss13 <br /> BUSINESS NAME. PHONE# <br /> 1-269) q, 1 1375 <br /> HOME or MAILING ADDRESS FAX <br /> rat r Rcu)C' R d (7An q31 - ZY7 3 <br /> CITY Skoc Y,�--O( /'Y STATE ZIP 526 <br /> I3ILLiNG ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, 1 t <br /> acknowledge that all site and/or project spccifIC ENVIRONMENTAL HEALTII DEPARTMENT hourly charges associated with this project or',:)�s <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 Ordin6nce Codes,Standards,STATE and FEDERAL laws. ' <br /> APPLICANT'S SIGNATURE: y ` DATE: <br /> 4Yon—.— <br /> PROPERTY I <br /> QQ—.—PROPERTY/BUSINESS OWNER❑ OPERATOR/MAKAGR; OTHERAUTnORIZEDAGEKT�M <br /> • IfAPPLTCANTis not the DIGGING PARTY.proof of authorization to sign is required Ttrfs <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I, the owner or:operator of the property located at the s. <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> • info"tion to the SAN JOAQUIN COUNTY ENVIRONMENTAL 14EALT1t 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:• AAJAJ-A<,e, �- <br /> COMMENTS: <br /> ILI <br /> APPRbYED BY: FMPLOYEE DATE:.' ?. L p , <br /> ASSIGNED TOC' <br /> EMPLOYEE : + DATEI O- 1 1 1 NI <br /> Dato Service Completed (If already c mpieted): SEINIGECODE; p.(E• I <br /> n , • 3is 2 <br /> boa <br /> Kemou O D Invoice# Amount Pald' Payment Date- <br /> -Pa ant T�e .4 ,Check# Recel4ed By; <br /> EHD 40-01.025' <br /> REVISELbrr,5.02 ` SERVICE REOtI((BTFORM '� <br />