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L7HIN J VHl1ULIN l.V UIN I Y v IN V Ll"kiiNlY, IN I Ilk L 11L'P►LI I1 "r I't1K I AIt Ir I <br /> SERVICE REQUEST <br /> Type of Business or Property FACII ITY ID#1 SERVICE REQUEST ff <br /> SR00 34-75 -' <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> 5US0.v, Cey,,ee LeN Qo\v I e <br /> FACILITY NAME <br /> SITE ADDRESS QIA 72 0' N Scicv i� 5 G • FAG�v��D 9SZ2� <br /> Street Number Direction Street Name Citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME J /J PHONE# EXT. <br /> 3 31( — 6 9 Z- <br /> HOME Or MAILING ADDRESS f FAX# <br /> g -2— ( ) <br /> CITY L 6 d ST 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 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: x DATE: K 7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 0'r11ER AUTIIORI-LED AGENT Lid L a h �� 'SVP-t/C'ti t3Y <br /> If T <br /> APPLICANT is not the BILLING PARY,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: ��vi c SU h 0.0 e Sv <br /> COMMENTS: � �frl� a 0 3 <br /> REcEivED <br /> X191-- <br /> ��� SAN JOACUIN COUNTY <br /> PUBLIC HEALTH SEFVICES <br /> Et;V!RONNIrt1TAL HEALTH DIVISION <br /> ell <br /> APPROVED BY: EMPLOYEE#: Z-� 2 DATE: `1 -3 f 0 3 <br /> ASSIGNED TO: EMPLOYEE#: 3 6 q DATE: —] 3[ -0 3 <br /> Date Service Completed (if already completed): SERVICE CODE: �+ 3 15' PIE: IL Q 3 <br /> Fee Amount: �,$ Amount Paid (11 Payment Date 3( O—;� <br /> Payment Type Invoice# Check# I,)�Z Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />