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I SAN JOAQUIN f'')UNTY ENvIRONMENTALHEALTH UEPARTMEN'I /1 <br /> ( / ) � <br /> SERVICE REQUEST 1 I�� { <br /> Type of Business or Property 'kj" FACILITY <br /> ' ID# �RVICE REQUEST# <br /> 3482, 0 3n9PAn +Re- -t MOt"11 <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> Vr,a$R 7W Amf1-- <br /> FACWrY NAME <br /> SITEADDRESS tr R`l f.l"tr,y ��►�' �L �f '* 9 Q <br /> Street Number Direction Street Name C ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) ottri•;s 1fY''�i:'Zg <br /> �'tr00 Street Number Street Name <br /> Cert STATE C•,c, ZIP <br /> PHONE#1 p Em. APN# OOS'-090 - S LAND USE APPLICA'nON It <br /> Lcz <br /> 9�.'i n r � — QO WSJ <br /> PHONEY G'Sl.L ExT' Y, BOS DISTRICT LOCATION CODE <br /> - <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQ:UESTOR CHECK if BILLING ADDRESS <br /> PHONE# ' <br /> BUSINESS NAME <br /> HOME or MAILING ADDRESS FAX# <br /> 4,2 T>h P ( <br /> CITY L n'f„ I STATE A ZIP 9S24 t0 <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: �z ,/�j �, DATE:{ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTU C"'` <br /> IrApPLICAM is not the BILLING PARTY proof of authorization to sign is 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 is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: RV7yIEVV 561L SO%TA6Vl.`I TY S-TVPY 0:0NI <br /> COMMENTS: <br /> I l� �3 zoos <br /> APPROVED BY: ♦'I •l <br /> d, ATE: <br /> EMPLOYEE#: 2'�� D1„ • 2 3- b 3 <br /> ASSIGNED TO: � � EMPLOYEE#: 3 f r DATE: v -'L3 -0 3 <br /> Date Service Completed (if already completed): SERVICE CODE: v�2 7 PIE: <br /> L 60 <br /> Pee Amount: ri Amount Paid D 1'/9— Payment Date 6 z3 D3 <br /> Payment Type �' Invoice# Check# _j S Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />