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2-01 <br /> SAN*QUIN COUNTY ENVIRONMENTAL HEAT DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER 1 OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME ,d <br /> Street Number -Dfreetlon Street Name ICf rip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) . <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1r AIN# LAND UsEAPaailcATtoN# <br /> ( } g 7- � .o <br /> PHONE t2 E)m SOS DISTRICTLOCATONC DE <br /> l ) C . <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> p6SINEss NAME PHONE En. <br /> 1 <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> CA <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 <br /> or 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: (APROPERTYI BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTBERAUTRORizED AGENT� j 1GF'>f 1'.��TA E <br /> IfAPP1.1C,4NT is not the BIL mgA4RM proof of authorization tosign 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 SA.NJOAQUIN COUNTY.ENVIRONMENTAL HEALTH DEPARTMENT as soon as it available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE RmESTED: ( ( S•7` [ PCOMMEWS: ANED <br /> SAN j0Ac�uw COUNTY <br /> AEWAV <br /> H-Od DE RR WENT <br /> i4CCEPTED BY: In It-1 V e 1114 EMPLOYEE M Jp 2— DATE: c C) <br /> ASSIGNED TO: v,¢�c f} EMPLOYEE#: DATE: l' <br /> Date Service Completed (if already completed): SERv10E CDDE: p I E. <br /> Pee Amount: - Amount Paid SLI Payment Date , <br /> Payment Type Invoice# Check# Received By: <br /> EHo na-02-025: <br /> REVISED 11117/2003 SFT FORK(Go)den Rad) <br />