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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR CHECK If BELLING ADDRESS <br /> FACILITY NAME � ,� C,` E V <br /> SITE ADDRESS <br /> Street Number I Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> 7-7 C( <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> { <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1 <br /> / C' v t( _ y� tom/ F/V JY;'ZSej ,"�! CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAMEL v c PHONE# ExT' <br /> `2 � �-� 30 <br /> HOME or MAILING ADDRESS (� FAX#{ <br /> � Z7 ,`,J , PA\ k✓tom (�J(1 T -� ! ✓-�� <br /> CITY �� �amp V STATE C_,4 ZIP 3 7 Z U <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 Cortes,Standards,STATE and FEDERA laws. , <br /> APPLICANT'S SIGNATURE: I-- - DATE: <br /> PROPERTY I BUSINESS OWN ERE] OPERATOR/MANAGER ❑ OTHER AUTHORI7F.D AGENT K -Sf t?-V 1'-'-- -r EC,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 ENVIRONMEN'rAL HEALTui DEPARTMENT'aS soon as it is available and aatt_tl�same time it is <br /> provided to me or my representative. PA Iv� N 1 <br /> TYPE OF SERVICE REQUESTED: � '�l7 r\� <br /> HV qA01 <br /> COMMENTS: LUUJ <br /> �� <br /> SAts 30P11111111 GoutslY <br /> ENVt>3oNM R TIlAiENT <br /> HEAL-341 OEPA <br /> APPROVED BY: y P<G� EMPLOYEE#: C' '� n�< DATE: <br /> ASSIGNED TO: EMPLOYEE M fL11 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid Payment Date r 1 I l (IPayment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />