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.rr�l. JvrL.jury. l.uU1Vl1 L' tv V11iU1V IVlA.lV lilt A/l.rW l'IJ+UL:I'AIt1'lVl1L:N'! � <br /> W w SERVICE REQUEST <br /> Type of Business or Property. }6�*x'^=1'?+iFACIUT•Y IDN' +ai ,i ;� SERVICE REQUEST;!{ X 2, i „ <br /> 3113 x <br /> OWNER OPERATOR CHECKIf BILUNO ADDRESS❑ <br /> >-7�e. e14 n 13e2 #0L0 <br /> . FAcarrr NAME <br /> !i ;Y�ADDRESS,.„Fwcf //1 C'rA3'j' Y�";��,f.:,� .ay ` . � u93�ya ,.... .�'�.�, <br /> Tree N mba e 1 ' <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> ' C /� L Slree N bar _ STATE Street NamZIe �1.. <br /> ' woo/J CA Y ( Ss <br /> PNDNE#1 ERT• APN0 LAND USE APPLICATION <br /> di UOY ) X93- -77/Y <br /> PHONE12 - ' ERT• �BOSDISTRICT7v�'�'%'ri. 'Y'Me .tiLOC11t10N�CODe, �Illfi` <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR •`'. `, <br /> 1'JS�/��r �'` �•' •/���) CHECK If BILLING ADDRESS L� <br /> BUSIN NAME - �T A/ PHONE ERT• !' <br /> v =/vc- minas 93-;z7/ <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 11C,6,6 C'-1 O u0 C --.cT STATE �1 ZIP 9 YO 65 <br /> aILLiNG ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENvIRONMENTALHEALTH DEPARTMENT hourly charges associated with this projector':;, <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 /> I, COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> + <br /> APPLICANT'S SIGNATURE: <br /> `�6f � : <br /> PROPERTY/BUSINESSOwNER2/ <br /> OPERATOR/MANAGER ❑ OrNERAUT110RILEDACENT11 - <br /> IfAPPLTCANT is not the Q/LLTNO PAR TC proof ojawhorization 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 environmenlallsilc assessment <br /> info4mation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available jado the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED:' Al O <br /> - COMMENTS: <br /> �' <br /> V <br /> �: Co•w . ., OLID N,O 0���PPP��J3��C1 <br /> RAN' �'pJBNMESI <br /> APPRbVED DY: EMPLOYEfi#:` S� .DATE:. <br /> ... .- . _. Irl <br /> ASSIGNED TOC' T 19 <br /> EMPLoS?EE IE: LlLl DATE: y <br /> DatoService Completed ,(if alreadycompfeted)`. SERVrA'GODE: 2(aU2 �.. <br /> Keo Amount:: L`S O Amount Pald: VS ',”Payment Date 1 p 1, <br /> Payment TypeInvoice#: ? .Check# l <br /> . .. Receive Byy <br /> EHD 48-01.025 <br /> REVISED 5;5-02 SERVICE REQlW7 FORM <br />