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i <br />Ui.ki 4 v11'k'ZU►,1v %,V Utv ,t a x.tv vllcVivivdLiV tfli, xxl,I Al I)LPAllIT LN I rr <br />SERVICE REQUEST 1 <br />lype or nusiness or Nroperty <br />AcuTY;ID'#'' �`� ¢•'wt{ <br />r: SERVICE REQUEST'O <br />i aN.IMp►y1t <br />OWNER I OPERATOR <br />HOME or MAIUNG ADDRESS <br />FAX # <br />r CHECK If BILLING ADDRESS ❑ <br />FACILITY NAME <br />I <br />ASSIGNED T0:'., <br />SITE ADDRESS <br />AT <br />SERYICE CODt • r <br />:S C r PIE: <br />eo`Amotint• ' ,Amount Pald <br />, , . <br />PaymentPate <br />Paymont Type : <br />r. <br />Street Number <br />ec I <br />a <br />1 ZIn Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Nu betstreet <br />N;me <br />CITY <br />STATE ZIP <br />' <br />PHONE #i Exr• <br />APN #. <br />LAND USE APPLICATION # <br />PHONE #; ' Ext. <br />e <br />BOS DISTRICTy'�4K�r�'9' I�n1 <br />;tOCATi01l`COD.t y�� <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR '. <br />CHECK ❑ <br />If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE #• <br />HOME or MAIUNG ADDRESS <br />FAX # <br />CITY STATE Zip <br />DXLLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENvtRONMENTAL 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: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHERAUTnORIZED AGENT ❑ <br />IfiiPP1JCANT is not the lIILL/NCPAg . 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 cnvironmental/site assessment <br />infbr nation to the SAN JOAQUIN COUNTY ENVIRONMENTAL 1113ALTH 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: <br />COMMENTS: <br />APPAVED BY: <br />F MPLOYEts <br />ASSIGNED T0:'., <br />: EMPLOI�EE�#. DATE <br />r n <br />Dato`Seivice Completed (if already completed): <br />SERYICE CODt • r <br />:S C r PIE: <br />eo`Amotint• ' ,Amount Pald <br />, , . <br />PaymentPate <br />Paymont Type : <br />r. <br />Invoice # <br />' <br />' <br />,Check # Received By <br />•I <br />REVISED,fr5-02 A <br />SERVICE RE001116T FORM ' <br />