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03/21/2003 09:19 4640139 ENVIRONMENTAL HEALTH PAGE 02 <br /> JAN J0A1QU1,JN �.�t'1 X L"Nvt1(()NM1+.N'1,'ALX16AW'11 JV K1'Ivl.1✓1�11 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ASoL1N E �Ulcc 6I 1olj <br /> OWNER/OPERATOR <br /> S 4€L1._ � i L ��v U[`-- C CHECK If BILLING ADDRESS E] <br /> FACILITY NAME (- R� ` �(�t S��—L J <br /> SITEADDRESS = D <br /> 2J Street Number I—PIrectlan r1 Street Name CI t21 Coe <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number el Name <br /> CIN StA M IE <br /> STATE ZIP <br /> PHONE#1 ExT• APN# LAND UsE APPLICATION# <br /> ) <br /> PHONE#2 EXT. 13OS DISTRICT -----fLOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I D i <br /> r,] II C K—tVG_)y L CHECK if BILLING ADDRESS <br /> BUSINESS NAME ' _I I\ IPHONE# EXT. <br /> Z5- 55>--7 4-4 4 \S-O <br /> HOME or MAILING ADDRESS FAx# <br /> _•� ��� 51� (9X51 SI - 75u8 <br /> CITY \ I STATE C ZIP q 45(e-,5t <br /> / ! _ <br /> DULING CKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific LNVIRONMLNTAL HcaLTH Df,;PARTMFNT 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 T()AQU1N <br /> COUNTY Ordinance Codes,Standards,STAT F6DFRnL s. <br /> APPLICANT'S SIGNATURE: DATE: /ZI 0 j <br /> PROPERTY/BUSINRSSOWNPR❑ OPERA OR/MANAGER OTHER AUTHORIZED AGENTPI NC ,an— tbQ— S\ILU 1 <br /> If APPL/GAT is not the BILLING P�1 NTY proof of authorization to sign is required Titre <br /> AUaTiQ ZATION TO RELEASE INFORMATION: When applicable, 1, 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#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE COOfi: PIE: <br /> Fee Amount: FAmount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br />