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y.. .___......_s.- _ -.sD T1 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQ111T 11 <br /> as OF <br /> OWNER/OPERATOR <br /> T' - T 19�� +, CHECK If BILLING ADDRESS <br /> FACILITY NAME -PAA 4 9--,66 /yJ <br /> SITE ADDRESS �Sf / / <br /> Number CiStei� eN <br /> Zi Code <br /> HOME or, I <br /> Mt7/AILIN•GG ADDRESS (if Different from Site Address) <br /> �" O 74}"l___- C f L' (J Street Number Street Name <br /> `T n <br /> CITY STATE , nJty- <br /> ZIP �—1 -3 <br /> 3,7 ,1 <br /> /� L�j l. <br /> PH�ON-EA#1 t� 7T APN# LAND USE APPLICATION# <br /> � r'$ I <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( S79 -� olU11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ' <br /> l 8 y %;7_1• S 7 9 -x(01 LI <br /> HOME or MAILING ADDRESS FAX# <br /> '-;?-�to -7 ST P�2 e�(� �f^ ( 7_CJ & 343 <br /> CITY n n .. STATE C4-1- ZIP 3 ? <br /> BILLING 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,Standards,STATE and FEDERAL laws <br /> APPLICANT'S SIGNATURE: DATE: <br /> 0 3 q 3'0 Er <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ AGER ❑. OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANTis not theBmUNGPARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I, the owner or operator of the property locaied 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 4Lthe same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: I A" RE C <br /> COMMENTS: <br /> SAN JOAQUINENTAsTM <br /> ENVIP�NM RTMENT <br /> H�p,LTH DEPA <br /> ACCEPTED BY: L U E--( eA- EMPLOYEE 2_y DATE: 3 /3 D0 <br /> ASSIGNED TO: EMPLOYEE#: ^ 'L DATE: c3 /3 O <br /> Date Service Completed (if already completed): 2.dg SERVICE CODE: b I PIE: dZ-31 <br /> Fee Amount: Amount PaidPayment Dated i (j <br /> Payment Type Imo, r Invoice# Check# ; _ Received By: T � <br /> EHD 48-02-025 E ? 10 <br /> ". ) <br /> REVISED 11/17/2003 <br />