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SAN JOAQUIN -)LINTY ENV1ItONMENTAL HEALTI eIJARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> n r1 CHECK If BILLING ADDRESS <br /> FACILITY NAME A r co S ,: -�O,- <br /> SITE ADDRESS i J �`\! <br /> StreOC(C.het Number Direction reef Name CI Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. qpN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE RE, QUESTOR <br /> REQUESTOR ('1 <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> - l�F o 1AACT1 C. S O" CosS*'( <br /> HOME or MAILING ADDRESS FAx# <br /> CITY A SIAzE ZIP s. <br /> � '� C-A t.� C(-� O r�S <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 I-IEALTH 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 FEDERAL laws. q <br /> APPLICANT'S SIGNATURE: ::� DATF,: 1 .`h 4 (0-S <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER El OTHER AUTHORIZED AGENT� tat,Q✓✓ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE 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 HEALTII 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: PAYMENT <br /> RECEIVED <br /> SEP z 4 20031 <br /> SAN,10P r-)I_'IN COUNTY <br /> APPROVED 8Y: EMPLOYEE#:, L' i-tpGO I LU DATE: Z _0 <br /> ASSIGNED TO: X1(1 EMPLOYEE#: 3 DATE: , ) u 0 <br /> Date Service Completed (if already Completed): SERVICE CODE: to P PIE: o p <br /> Fee Amount: Z C� Amount Paid — Paymentf Date 0 <br /> 0 <br /> Payment Type �% Invoice # Check# /, �`� Received By: ; <br /> 1L <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />