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JW,yU1iVa,uuivtYL'1vv1KUiV1v1t�;1V'1E1Lt1L I)EPAKIMENT <br /> WSERVICE REQUEST <br /> Type of Business or Property m r � -, <br /> �,. FAC{CITY ID# [ � SERVICE REQUEST# _ r, <br /> C, ) V 0 CkR` a i® \ •• e\ V \" o`vv, $�Na f yyt yh j.2'2�a..yT;4�`��G S t! ?!. ti� i4 � 4 �k . <br /> !� <br /> \ �.. -...� �'t^.t..: ••St"i t„x. ....'•xC1'�.h�-.�.: � ♦.' �l..< ': .t...;%f+P ..—;!:Y.A' t7S ' <br /> 0 (NER 0 OPERATOR <br /> OCHECK if BILLING ADDRESS rN <br /> FAcnrIY NAME '+1 <br /> 1 SITE ADDRESS...'" �l .{Y'�2, �' t Y\ ._ _ `5 TU;C _-� 17 -2 <br /> �. <br /> i• Street Number DI Inn i Street Name CI ZI Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> StreeIN b Strew <br /> CITY � � � ` � STATE � ZIP <br /> PHONE#'I 1 Ext. APN#, LAND USE APPLICATION# U !. <br /> do,-,) <br /> PHONE#2 EXT. BOS DISTRICT 'vim r' LOCATION CODE <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR :— <br /> 1 CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# <br /> T 61 <br /> HOME or MAILING ADDRESS F # <br /> .2. 35 `� � <br /> Or ) l-16 1 - L12 <br /> (X� STATE c ZIP 01T <br /> BELLING 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,Stan rds,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNA DATE: I _ 2 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 1 C _ <br /> If APPLICANT is n e BxUNCPARTY,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 14EALTH 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 /> 'APPROVED BY EMPLOYEE# �� 7 WE <br /> ASSIGNED TO EMPLOYEE# rP { ®ATE: # ik <br /> _. . <br /> yyeti <br /> a <br /> Datta Service Completed "(ifalready cotnpteted)7, SERVICE CODE P!"E <br /> A <br /> Fee Amount: Amount Pald :; ,, Payment DateVF, <br /> ' -. .. - .. .. ...fix. ...... .•k t..^." <br /> Payment Type =" Invoice# Check# Received By <br /> EHD 48-01-025 \ SERVICE REQUWT FORM <br /> REVISED 6;5-02 <br />