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JAN J('AQU11N l.OU1N 1•Y L' 1N V1KU1N1VILLN IAL I-ILAI i t1 "k–eAR1A1hi1% 1 <br /> SERVICF REQUEST <br /> Type of Business or Property FZILITY ID# SERVICE REQUEST# <br /> i( OuL S5 <br /> OWNER/ OPERATOR CHECK If BILLING ADDRESS <br /> � <br /> FACILITY NAME <br /> SITE ADDRESS X/ � q e /1 calf v �L�Z Z v <br /> -76-7 Street Number D ion Street Name t"7 Ci ••/Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> / _ — <br /> PHONE#1 EXT. APN# LAND USE APPL A OtJ# <br /> (W9 ) T— I — Z(�Z Ass c- <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> e- <br /> � CHECK If BILLING ADDRESS <br /> BUSINESS NAME - <br /> ExT• <br /> Z�•) -334Z-- - -3 <br /> HOME or MAILING ADDRESSFAX# /j <br /> • Z zl I/W . Qg� S� ��c�•` �� c2l�J ) �-f- [�rCr I <br /> CITY / / STATE(fA ZIP 5Z40 <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 laws. <br /> APPLICANT'S SIGNATURE: DATE: —� —© �L <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT y �f GiL1` <br /> IfAPPLICANT is not the BILLING PART);proof of authorization to sign is required Tirle <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 environmentaUsite 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 /> TYPE OF SERVICE REQUESTED: 2--F,4 Gh i-1-44 <br /> COMMENTS: 3/t,)/e cr <br /> PAYM E N T <br /> C3 RECEIVED <br /> JAN 1 8 2006 <br /> SAN JOAQUIN COUNTY <br /> APPROVED BY: LC EMPLOYEE M C, HEALTH DD/t TMfE /� ��CL-CV�c � <br /> ASSIGNED TO: M �� , ,C EMPLOYEE M S 3� DATE: ` I <br /> Date Service Completed (if already completed): SERVICE CODE: I PIE: <br /> Fee Amount:, �n O�D Amount Paid 1� g(L Payment Date <br /> Payment Type Invoice# Check# �q� Received By: j <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />