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01:/19/2002 12:45 4640138 f ENVIRONMENTAL HEAT TH PAGE 01 <br /> J,,4..N JOAQUI.N l U1J.N"I'X �NvIKV�VM��V'�A1.k1k:A1��kI���.K"I'M�N� <br /> SERVICE REQUEST <br /> Type of Business or Property F ILITY ID SERVICE REQUEST# '. ... <br /> OWNER I OPERATOR CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> U \ S40 <br /> 'A <br /> SITE ADDRESS 7o'�7 9 <br /> Street Number I Direction Name <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number m <br /> CITY STATE zip <br /> PHONE#1 APN# LA.ND USE APPLICATION# <br /> 12- <br /> PHONE#2 EXr• $0$DISTRICT T"` � r; '` LOCA1i6fJ CbDE `�"�' <br /> '74r.*�.:.•ri.;,i.v 5:�' ;�•.. '�:'- ?�� +,�� ;�"moi::. a��r. <br /> Y' <br /> CONTRACTOR/ SERVICE R.EQUESTOR <br /> PRQUESTCR ^n CNECKIfBILLINGAQDRPSs� <br /> BUSINESS NAME P 0 # r <br /> 1 (QQ 4e <br /> v' 0 - -,-6z <br /> HOME or. AILI gID E S FAX# <br /> Cin? /0-5 <br /> TATE zip <br /> BILLINC ACKNOWLEDCEMENT: I, the undersigned property or business owner, operator or authorized agent of same,. <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HF-ALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to we or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performcd will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards ATE and FEDERAL laws. <br /> "P LICANT'S SIGNATURE: DATE". <br /> PROPERTY/BUSINCSSOWNER❑ OPERATOR/MANAGER HERAUTHORizEDAGENT <br /> 1aV \ <br /> If i1PPLlCANT is no!the BILG& ARTY.proof of authorization to sign is require Title <br /> AU'I'l"BR&1ION TO RELEASE INI.OPMA170N. When applicable,T,the owner or operator of the property located at the <br /> above site addiress, hereby authorize the release of any and all results, geotechnical data and/or environmental/sitc assessment <br /> in£ornvition 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: <br /> ,APPROVEDIBY:. '... EMPLOYEE#: . �.' DATE: <br /> SIGNF�TO: EMPLOYEE i'�•. 'DATE: <br /> As 3:j°: .. :: <br /> -. <br /> pate Service'Ctimplate (It already completbd): 8 P f E: <br /> t=eed Amount: •Amount Paid <br /> 0'2(p� .. � .: Payment Date <br /> Payment Type �j''• Invoice# Check# .' kecotvod By. : <br /> EHb 48-01-025 SERVICE REQUEST#CORM <br /> REVISED 6-5-02 <br />