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SAN JOAQUI.N C )t NTY El NVIRONMLN`1'AL HEALTH' i AR`1'MEN'r <br /> SERVICRQUEST <br /> ' <br /> Type ol`Busindss or Pro ert <br /> k YP p y FACILITY ID#. SERVICE REQUEST# <br /> s�DQ3-A?D6 <br /> OWNER/OPERATOR <br /> CHECK H BILLING ADDRESS <br /> FACiuTY WmE C��/+ /�T2 <br /> SITE/ADDRESS <br /> 09 i ' C�• /r ,y4wv 2T 'kI r� �4'L _ Gf� 9J_3 3/� <br /> Street Number Directiart I ' Street Name ,. CityZi Code - <br /> HOME Or MAILING ADDRESS'(If Different from Site Address) <br /> tiSlreet Number Street Name <br /> CITY � 7�f C STATE ZIP <br /> ?:57 3 3 <br /> PHONE#1 XT. APN H <br /> /10 <br /> ^ LAND USE APPLICATION# <br /> P- <br /> 1' PHONE#2 EXT. <br /> BQ$DISTRICT LOC ' <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESSO <br /> BUSINESS NAME -r.PHONE Ex <br /> HOME Or MAILING AuDRE-ScVFAlc# <br /> f ,�, t!rc.� (noel) S 8 -5 <br /> 3 <br /> CITY /O ?/ STATE, ZIP 5;;'J— <br /> BILLING <br /> �J— [� <br /> BILLING ACKNOWLEDGEMENT:-i, the undersigned property or business owner, opera/tor or authorized ,agent of sante, <br /> acknowledge thaulli 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 prepated this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, ar s, d FEDERAL laws. <br /> APPLICANT'S'SIGNATURG: �� r'v „v 6/ <br /> PROPLRTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGRNT❑,_ _ , �� <br /> f lfA,11PLICANT is not the BILfING PARTY,proof of authorization,too sigrl is required rifle <br /> AUTHORIZATION TO RET EASG_INFORMATION: When applicable, I, the owner or operator of the property located at t e <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 rcpresentative. ' _. <br /> 11 <br /> TYPE OF SERVICE REQUESTED: c pA. �vE 3a <br /> COMMENTS. <br /> oAaU�N s°RM ,oN <br /> 30 <br /> APPROVED BY: i EMPLOYEE#: DATE: 0 <br /> ASSiGNEa TO: EMPLOYEE# DATE:, ✓ <br /> f Date Service Complete (if already completed': SERVICE CODE: 4�� p t <br /> / <br /> E; /_D <br />` Fee Amount:: f't� Amount Paid Ll 4 S-. 6 Payment Date 0,-f01b;3E( <br /> Payment Type'' ` ✓ Invoice# i Check.# Received By;. <br /> , � <br /> HD 48-01-025 SERVICE,REOUESt FORM ' <br /> yfIHV15Ed 6-5-02 V "- r <br />