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Vt1.11Ul UUIV 1 Y L' Iv V11WiN1V1L1N l kG 11liA.1L1'H I)ET lt•1'i EN'1 <br /> SERVICE REQUEST <br /> ~Ty ''�f Business r roperty ,U- ; FACILCLY:I # SERVICE REQUEST#r ,� <br /> 3tI <br /> ' <br /> kr n-'�1�' .. ry 'I � ,..•Y �T yT'�`ay r� ,�����_ T 1',•c �t�'Z..�lf};.�, <br /> OW R/OP OR <br /> CHECK if BILLING ADDRESS <br /> FAciuTY NAME &P-CI"Ift <br /> ;y <br /> SITE ADDRESS <br /> �} <br /> M150 �' �j <br /> Street Number Direc ton S r ame �itd,,, <br /> HOME Or MAILAILING R SSMIorent from Sit dress) , <br /> , <br /> Street Number St me <br /> i <br /> CITY ]STATE <br /> '� TATE ZIP <br /> Vt —,f ( a-/ .- <br /> PHONE# Eire APN# LAND USE APPLICATION# <br /> PHONE Z EXT. BOS DI�STRIC�TII{ti ^ ✓��? LOCATIO�N?COUE"^K `qr <br /> �� / 1 � ia'r'y�e�•x'f�� i.��3-��-,t`\[r�•7���i i �^Ia`1Ff'.tf �9r �. <br /> CONTRACTOR^VICE REQUESTOR <br /> REQUESTO <br /> CHECK If BILLING ADDRESS <br /> 7 <br /> BUSINESS NZe— PHON EXT. <br /> HOME or MAIUNG/ADD FAx# <br /> CITY TE ZIP <br /> BILL G 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 foram. <br /> I also certify that I have prepared thm4wiplication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stand d FEDERAL laws.. <br /> APPLICANT'S SIGNATURE: Y L DATE: <br /> PROPERTY/BUSINESS OWNER❑ OFERATO~A OTHER A(rr}IORIZED ACEIvr <br /> If APPLICANT is not the BiLuNGPAR7Y of of authorization to sign is required Title <br /> AUTHORIZATION TO RELtASE 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 environmentaUsite' 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:' T <br /> COMMENTS: <br /> SPN JONEP�S R`n01A3�ON... <br /> .l <br /> APPROVED BY r << EMPLOYEE# ; DATE: <br /> ASSIGNED <br /> TO"" EMPLOYEE <br /> e. S r <br /> T <br /> Dani Service Completed (tf already completed):. _' SEINU CODE r:. P!E•"r <br /> M r�r 3 <br /> f <br /> dee Amount :' [ ° p Payment Date <br /> Amount Pi <br /> Payment Type Invoice#"• Check# Received By EHD ' <br /> REV SED(1 -0 \ SERVICE REQU�T FORM <br /> REVISED 665-02 <br /> A. <br />