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OPWA J kJAQ V u1N ! Y L' IN V 11CUiNIVILIN'I'AL -r-LL lUk:YAIZl'MLN'1' <br />r ' SERVICE REQUEST 1 <br />A <br />s <br />Type of Business or Prop rat <br />CHECK if BILLING ADDRESS <br />+ FACILITY ID # <br />tJ'kf <br />'R� <br />SERVICE REQUEST # r N� <br />t+i <br />OWNER I OP <br />HOME or MAILING ADDRESS <br />d <br />CHECK if BILLING ADDRESS <br />FAcumrNAME <br />STATE Z!P <br />APPROVED BY:-.-:._.. <br />SITE ADDRESS <br />ta <br />{ * = <br />EMPLOYEE # z: t� .. <br />4S110 <br />Yr <br />1k14CItyZ! <br />Street Number <br />DI i n <br />Name <br />EMPLOYEE # c " <br />Code <br />HOME Or <br />from <br />Slte Address) <br />=RE7(rrent <br />SERVICE CODE <br />.7 <br />PfE lyyr�{ M ` <br />Street Number <br />Street Name <br />CITY <br />t <br />Mr ZIP <br />no <br />PH NE #1 <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />EXT. <br />BOSDlsTtilcT "` �' 5r <br />LocgnoNCone <br />CONTRACTOR / SERVICE R <br />REQUESTOR <br />UWAU-__ I fiwwj — <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME '. <br />1 0 ed, � 1, 0 b 0, �-_ - <br />�, . —1 <br />PHON' <br />HOME or MAILING ADDRESS <br />d <br />FAX # <br />) 1" <br />CITY <br />STATE Z!P <br />BILLING AC DGE NT: 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 projector <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, Stand r s, STATE and FEDERAL laws. <br />Z <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 8 <br />If APPLICANT is not the BILLINCPARTY proof of authorization to sign is required Ttcte <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 renresentative_ <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />APPROVED BY:-.-:._.. <br />{ * = <br />EMPLOYEE # z: t� .. <br />DATE ,� . ` � '-Pu. gk> , <br />Yr <br />� w <br />ASSIGNED 70 <br />r <br />EMPLOYEE # c " <br />DATE <br />Date Seivict3 Completed "(if already completed): <br />SERVICE CODE <br />.7 <br />PfE lyyr�{ M ` <br />t <br />Fee Amount <br />Amount Paid <br />;l <br />Payment Date <br />k_4 ; <br />Payment Type <br />Invoice # <br />`, <br />Check # =' <br />Re t:etved By ' <br />-:. <br />EHD 48-01-025 <br />REVISED 6.-5-02 <br />SERVICE REQUWT FORM <br />