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• ���--���quo <br /> • SAN JOAQUIN ( JN'I'Y LNVIKONMLN'1'AL 1-1LAL'1'I Isl'AK'I'IVII;N'1' Sw/� �� <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST b <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADD s—) , I %� N� t � <br /> SlreeI N mber Dtrcclton Ir el Name Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Slrcel Number Slrccl Name <br /> CITY STATE ZIP <br /> PHONE 11 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE 12 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICERI:QUI;STOR <br /> FFREQUESTOR <br /> CHECK If BILLING AODRES. <br /> BUSINESS NAMEPHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> I1AANG ACICNOWLEDGLMUNT: I, the undersigned properly or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMEN'T`AL HEALTI1 DGPAItTMENT 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 (his application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FGDCRAL laws. <br /> -APPLICANT'S SIGNATUItE: DATE,,: <br /> 11ItormtTY/BUSINI%S OWNEROPEsRATOR/MANAGER ❑ OTIiKR AuruoRizrD AGENT❑ <br /> ifAPPUCANT is Hot the IJILLING PAITT proof of authorization to sign is required Tirle <br /> AUTHORIZATION TO RLLrASC INFORMATION: When applicable, 1, the owner or operator of(he 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,LNVIItONMGNTAL I-113ALTH 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 /> F.p1V1R <br /> APPROVED BY. EMPLOYEE#: (` j l DATE: <br /> ASSIGNED TO: ^I > '� EMPLOYEE DATE:, <br /> Date Service Completed (it already completed). SERVICE CODE: C' P J E, :23 <br /> Fee Amount: (;-' Amount Paid 9-7— Payment Dale <br /> Payment Type L� Invoico# Check# ZZ-�_ Received By: 7l� <br /> EHD 48.01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />