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J LIN �_V UI`I I Y l' 1v VJJkUiNlvll'1N IJVL JL11',, LJ• 1JE1'iVC1•M.l',NT <br /> '� • SERVICE REQUEST <br /> Ty '•?f Business r ropertyFACILITY:I # :SERVICE REQUEST.01+TOPM '# ryf } <br /> OR ,. . <br /> t CHECK If BILLING ADDRESS <br /> FACILITY NAME 1 <br /> i STEADS <br /> Street NumberDirec 1 n ask.. PkIlL, ((iL <br /> ct <br /> 6 ZI Cod <br /> HOME Or MAILING R�SS f DIf Brent from Sit dress) <br /> ~ = . ' <br /> Street Number Stree Na e <br /> ' = <br /> CITYISTATE ZIP <br /> PHONE# ExT. APN# LAND USE APPLICATION# <br /> PHONE 12T• BOS DISTRICTRijti`s� a ✓'` LOCATION CODE"^K <br /> (Cz, q A30 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTO _• <br /> CHECK If BILLING ADDRESS <br /> BUSINESS N PHON F'rT <br /> HOME or MAILING ADD FAx# <br /> CITY TE ZIP <br /> BILLI 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 form. <br /> I also certify that I have prepared this pplication and that the work to be performed will be done in accordance with all SAN JoAQUIN <br /> COUNTY Ordinance Codes,Standar , TA"d FEDERAL laws.�M4 <br /> APPLICANT'S SIGNATURE: v DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER EI OTHER AUTHORIZED AGENT <br /> A If APPLICANT is not the BILLING PARTY proof 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 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 representative. <br /> TYPE OF SERVICE REQUESTED:- "r I e (- <br /> COMMENTS: <br /> • CO <br /> N J()PQ�P�SH S R 0\\J\QN0" <br /> • P?\0�\E�4 � <br /> • ENV\ROHM .. <br /> APPROVED BY EMPLOYEE# y DATE' <br /> ASSIGNED TO {` t �' r n;a y EMPLOYEE# i ? q�uua DATE Se k <br /> Dani Service Completed (If already completed): ,yk SERYIGEGODE 't <br /> �ee'Amotint. Amount Paid .,,. Pa ent Date <br /> Payment TypeInvoice# Check# Re6elved By `�W <br /> �(. <br /> 6SERVICE REQU�T FORM025 <br /> REVISED <br /> tir5-02 . <br />