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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID If SERVICE REQUEST# <br /> Res (Je-o4-icy,( 14PN of)5-IL+ - 3 �a � �1 'g3yCJ , <br /> OWNER/ OPERATOR <br /> Ru T M . M a r S I I CHECK If BILLING ADDRESS <br /> FACILITY NAME J 'J,57-22- <br /> C- <br /> SITE ADDRESS2 C' 1W aO C/ SDo Rq . �Cawt/PO // 220 <br /> Street Number Dlrtttlon Street Name Cit ZI Code <br /> HOME or�MAILING ADDRESS (it Different from Site Address) <br /> Street Number Street Name <br /> CIN STATE ZIP <br /> PHONE#t EXT- APN M LAND USE APPLICATION N <br /> PHONE1112 EXr. BOS DISTRICT LOCATION CODE <br /> ( ) 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR -( F CHECK It BILLING ADDRESSa <br /> EQNI'tC$ 1 f �1M �T4 <br /> BUSINESS NAME <br /> PHONE If A? EXT. <br /> Gt V I L / 3 — / 3 7✓ <br /> HOME Or MAILING ADDRESS FA%# <br /> 2 X-1 W . 0 Q.L S . � —Z ( ) � – 7,373 <br /> CITY L _ D STATED p ZIP -6--.1 <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 c6rtify 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: c _ I DATRRRr: —a3 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTIIORIZED AGENT G Ir/6 L 6tiV ✓� <br /> If APPLICANT 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 environmentaVsite 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: ft� SOL S t S <br /> I_ <br /> COMMENTS: �/ 3 ?E E!VED <br /> L APR 16 2003 <br /> (p a �PN.1�J JJIN IUNiY <br /> °111111^HI f A'!CCS <br /> APPROVED BY: EMPLOYEE#: DATE: f <br /> ASSIGNED TO: � ,,,� EMPLOYEE#: - DATE: <br /> vt <br /> Date Service Completed (if already completed): � <br /> �(� j SERVICE CODE: �`-2� P/E: �JI <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice It Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />