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SAN JOAQUCOUNTY ENVIRONMENTAL HEAI ` DEPARTMENT <br />16 SERVICE REQUEST <br />"1111LfBusi ess or Property <br />Ty a of <br />FACILITY ID # <br />7 <br />SERVICE REQUEST # <br />Lm } <br />Qrz <br />/ <br />f��(',�W w `� <br />.5�00T91 3 <br />OWVAIERI i PER O � � <br />'(--f l <br />CHECK if BILLING ADDRESS E] <br />FACILITY NAME <br />C�;?5 ,35 d, 00a lIol <br />EMPLOYEE #: 2 <br />SITE ADDRESS <br />4,U 1-6-0,VZ <br />CITY <br />DATE: wvio , 3 <br />/l1 <br />IP _,, <br />Street Number <br />Di7e�tion <br />reef �me <br />Amount Paid 1 -7 e7 . <br />Cit <br />Zi Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Check # 75-T7 <br />L, <br />` f5 ` (1' CL Street Number <br />Street Name <br />CITY <br />(�TATE ZIP <br />- _ <br />1 . <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( )qI/,�-ocl/ � 2- - <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />At I /� <br />COMMENTS: <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />/ <br />f��(',�W w `� <br />PHONE <br />EXT* <br />6 <br />HOME Or MAILING ADDRESS <br />C�;?5 ,35 d, 00a lIol <br />EMPLOYEE #: 2 <br />(A !) <br />4,U 1-6-0,VZ <br />CITY <br />DATE: wvio , 3 <br />ATE <br />IP _,, <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 HEALTI-1 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 applic tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards,STT a EDE llaws( j <br />APPLICANT'S SIGNATURE: RoAb DATE: <br />PROPERTY/ BUSINESS OwNFR ❑ OPERATOR / MANAGER ❑ OTIIFIt AUTIIOItIZFD AGFNT � -606 , <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTI-IORIZA"CION 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 HEALTI-I DEPARTMEN"f as soon as it is available --at the same time it is <br />provided to me or my representative. p�� tttt i <br />TYPE OF SERVICE REQUESTED: I r t <br />s <br />COMMENTS: <br />SEP <br />pU1N COUNN <br />SERVIOMSION <br />SPUBLICC <br />OEALIH <br />HEAL H <br />ENVIRONMENTAL <br />APPROVED BY: �- <br />EMPLOYEE #: 2 <br />DATE:�(0 <br />ASSIGNED TO: <br />�. <br />EMPLOYEE #: 4 + <br />DATE: wvio , 3 <br />Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: '2— <br />ZFeeDate <br />FeeAmount: <br />Amount Paid 1 -7 e7 . <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # 75-T7 <br />Received By: <br />END 48-01-025 SERVICE REQUEST gkf- <br />REVISED <br />6-5-02 <br />