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JAN JUAQU1N %—OUN 1 Y L'N VIRONIVILN IAL I1LAL1111 rH;YAKI MLN 1 <br /> `- SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> A - Res /C? <br /> OWNER/ OPERATOR <br /> CHECK if BILLING � <br /> NOADDRE55 <br /> -kj t1`7 it G <br /> FACILITY NAME <br /> SITE ADDRESS Q Z 0 C Uh �/''�D�� 57 ami L-y 5 Z <br /> / Street Number Direction Street Name i Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SCC e Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> 1 ) 1007- 3 /o {ofd ' L'77 .. <br /> PHONE#2 EXT BOS DISTRICT LOCATION CODE <br /> 1 ) 0 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR el e e / CHECKIf BILLING ADDRESS <br /> BUSINESS NAME/ PHOS# �� E <br /> HOME or MAILING ADDRESS L (A%# )�� �� / <br /> z 0, Oak S-f Sfe 8 z-- 4-- <br /> CITY / O 1:1-:6 STATE /A zlP 9,5240 D <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: O 7 <br /> l i <br /> PROPERTY/BUSINESS OWNER❑ PERA R/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> /f APPLICANT is not the BILLING PART r proof of authorization to sign is required J 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. -T <br /> TYPE OF SERVICE REQUESTED: RECEIVED <br /> COMMENTS: COUNTY <br /> SAN JO VIOQUIN NM ENTAL <br /> ENVIRONMEAE <br /> HEALTH DEPARTMEPIf <br /> APPROVED BY: EMPLOYEE#: Ll I <br /> DATE: YZ/6/07 <br /> ASSIGNED TO: �. EMPLOYEE#: DATE: <br /> Date Service Completed if already completed): SERVICE <br /> Fee Amount: l Amount Paid Payment Date Lf0 <br /> Payment Type Invoice# Check# 3-1f Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />