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OL11V .J UAkyULIN l.UU1V 1 Y 1 <br /> SERVICE REQUEST <br /> r Iy e of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � 7ff 562-to ` <br /> OWNER/OPERATOR <br /> � CHECK <br /> 0 U) C c-') \f\'\ <br /> FACILITY NAM © \ <br /> SITE ADDRESS 'L�OO -Q— Lc,k"v-,('c>P �S33b <br /> Vv Street Number I Direction\ Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> c 1 <br /> 1 Le�� n <br /> l – Street Number Street NN <br /> CITY )e CA` - �_ STATE ZI I C� <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (20'—A )13 - b 3$ \ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> c 66) 16 -u3s <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR _ _ <br /> �O �� �C'LAO v ` C Q_ �("—\,3 <br /> \, CHECK If BILLING ADDRESS <br /> BUSINESS NAME^ �J PHONED# EXT. <br /> t � \\ e- �U ( -C) c.c}o�� o2 633 <br /> HOME or MAILING ADDRESS FAX# <br /> 25 -1 W c 92— <br /> CITY <br /> CITY �a� � 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 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,Standa ds,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: C W DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTIIER AUTHORIZED AGENT" <br /> If APPLICANT is I 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 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: R EC's L V E D <br /> NO 10.E <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH niVISICtj <br /> APPROVED BY: - ^ EMPLOYEE#: DATE: 1 l '? 6 rl <br /> ASSIGNED TO: b� l J L� _ EMPLOYEE#: DATE: <br /> 1 r <br /> Date Service Completed (if already Completed): SERVICECODE: C� P/E: ,2'30 <br /> Fee Amount 1 Amount Paid Payment Date i; <br /> Payment Type Invoice# Check# j��3 Received By: 616 <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br /> �a <br />