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0111N JkJL1l1U11N %. kjU1N IT 12AN V 11tV1N1VIL'IN IAIA LIE''AI.1 lY 'ul"rA1'k11VI1S1N 1 <br /> .r, SERVICE REQUEST <br /> Type of Business or Property FACILITY Ila# SERVICE REQUEST# <br /> 5-1 le 159e 3/ <br /> OWNER/OPERATOR 21 <br /> J01-7,o CHECK if BILLING ADDRESS❑ <br /> FACILITY GAME <br /> SITE ADDRESS � 1A)t /,C ,9�710L' <br /> Street Number Direction Street Name Ci Zi Code ' <br /> HOME Of r MAILING ADDRESS <br /> � fDDRESSS/,!�(it Different from Site Address) <br /> "" <br /> S - f•12 W S 7 #J 6 Street Number Street Name <br /> CITYLSTATE ZIP t�ol /I '-�7'5a �1L <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESSOR CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT. <br /> air 3(,9 -d O7 7 <br /> NOME Of MAILING ADDRESSn FAX# <br /> Iaa5 LLL- 412,MSlkprJ U Art (A0-�' ) 3S <br /> CITY ( cp TATE Z'!P <br /> -le '9 z <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 and FEDERAL ws. <br /> APPLICANT'S SIGNATURE: �--�-- M DATE: 57A�S/U 2— <br /> PROPERTY I BUSINESS OWNER 'P---T-OR/MANAGER ❑ OTIIER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Titte <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 is available and at the same time it is <br /> provided to me or my representative. <br /> p TYPE OF SERVICE REaUESTED: y <br /> COMMENTS: <br /> � <br /> ` r <br /> v ff <br /> PAYMENT <br /> RECEIVED <br /> SEP4252002 <br /> APPROVED BY: EMPLOYEE#: PLD <br /> I�t�,�.q�� <br /> E N A R N�IENIAI.H 2— <br /> ASSIGNED TO: EMPLOYEE#:(-'7� r( DATE: <br /> Date Service Com ted (if alrea completed): SERVICE CODE: :=P <br /> Fee Amount: Amount Paid — =Payment Date Ct <br /> Payment Type �/ invoice# Check# ,y ,L f Received By: 1 ' <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6.5.02 <br /> s <br />