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SAN JOAQI*COUNTY ENVIRONMENTAL HEAiv DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C � tr[dQ40451 11 <br /> OWNER/OPERATOR <br /> vakk I Ncll�'Y CHECK If BILLING ADDRESS <br /> FACILITY NAME r/ <br /> c,. kc\Cic �(ekN-o�e:.w. SGrVtLC! (V PPS — fool <br /> SITE ADDRESS <br /> Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> bL r CtYc-\ Street Number Street Name <br /> CITY t - STATE ZIP <br /> tic- if li Of v (o <br /> PHONE#1 ExT• API# LAND USE APPLICATION# <br /> (' ) �Nfs Sylz <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR <br /> �jrp T f V�,i o c., CHECK If BILLING ADDRESS <br /> X7�r. <br /> BUSINESS NAME PHONE# EXT. <br /> HS�rn Pa�o-otT Caxt .t�cd'~ Jwc a) �7$ - 6ff3 `f <br /> HOME Or MAILING ADDRESSFAX# <br /> PP• gew ^i b 5 (.136 ) r67S' W(3 g <br /> CITY /`t"c-�VJ�A l ,ITV\' STATE CAr ZIP &per <br /> CI r � <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 farm. <br /> I also certify that I have prepared this application and that work It be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stnndartls TATE and F RA <br /> APPLICANT'S SIGNATU /G- o <br /> ,,,��}..,,J// DATE: �� 1 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof))o 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 env-{ronmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it ' nd at the same time it is <br /> provided to me or my representative. PP Ew� <br /> TYPE OF SERVICE REQUESTED: U,y feffr JJ IV <br /> COMMENTS: <br /> gANOPO lTN 5 P�CESS\ON <br /> EN`1\PUNMENT AY HEALSH ON <br /> APPROVED BY: EMPLOYEE#: Z L g 2 DATE: C✓— "20 -03 <br /> ASSIGNED TO: EMPLOYEE#: I DATE:-7 �'- 10 Y 03 <br /> Date Service Completed (if already completed): SERVICE CODE: 1 PIE: -130F <br /> Fee Amount: T Amount Paid �j � -_ _ Payment Date <br /> Payment Type Ll� Invoice# Check# 2--3Received By: <br /> EHD 4MI-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />