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SERVICE REQUEST <br /> Type of Busin or Property FACILITY ID# SERVICE REQUEST# <br /> S4Z00 (4X,5 J CC <br /> OWNER I OPERATOR �"^� <br /> CHr-cxif BILLING AoDREs&L.1 <br /> FACIUTY NAME <br /> SITE ADDRESS - W e a c16'0-i d Qe A S <br /> i t v 7'v cJ <br /> I Street Number DireeUon Street Name .0 zip Code <br /> HOME or'MAium ADDRESS (if Different from Site Address) <br /> Y� A 'T SVeet Number Street Name <br /> CITY STATE ZIP <br /> G cz-vvt � 2 2 p <br /> PHONE#1 �• APN# LAND USE APPLIGIA'nON# <br /> _ 41/7 2 0_!p, /9 P15L a f —2- IC-73 <br /> PHONE 92 Ext. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REQUESTOR �( <br /> /� CHEcKit BiLuNG AODREssLAIJ <br /> BusINESS NAME f� PHME# Err. <br /> 33 `f-- z <br /> HOME or MAILING ADDRESS, I �, 19a-k 5�_ f� B Z FAX# <br /> - <br /> CITY ' STATE<- 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 ENVIRONME!NTALHEALTH 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 c4rtify 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 andFEDERAL laws. <br /> . �, o � <br /> APPLICANT'S SIGNATUR1020 <br /> E: DATE; <br /> c PROPERTY/BUSINESS OWNER❑ OPERA O AGER ❑ OTHER AuTitoRIZEDAGENT <br /> .4-Le <br /> If APrtJCANT is riot the Blu.ING PA1eT?:proof of authorization to sign is required Ti k <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 ENviRoNMENTALHEALTH 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: �e f/1 Gw, Sa i Sv/flc 6l�i S '� <br /> t;oMfdEHTs: <br /> APPROVED 8Y: EMPLOYEE : 9,6 DATE: d .� <br /> ASSIGNED TO: ~ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE:. PIE: <br /> 6 <br /> Fee Amount: Amount Paid Payment Date 1 61�Izl <br /> Payment Type L� invoice# Check# �)_G'` X7 Received By: <br /> EHD 48-01-025 SE=RVICE REQUEST FORM <br /> CtFVi.SFr1 F-S-O2 - <br />