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Me 91 <br /> SAN,JOAQUIN ,.�UNTY ENVIRONMENTAL HEAUI'.,..,)EPARTM <br /> SERVICE REQUEST Awn <br /> Type of Business or Property FACILITY ID If SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK U BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS l 7 0pLJ /T,�'/S e 69�A�TE//Z- GU�• �T�C�/ 9SZo 6 <br /> Street Number Directlon Street Name ZI Code <br /> HOME or MAILING A DRESS (If Different from Site Address) <br /> Street Number StRRn Name <br /> Ctrr Seo ATO ti� STATE ZIP <br /> PHONE#1 EXT• APN R LAND USE APPLICATION# <br /> I ) <br /> \ PHONE#2 EXT- BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECKIf BILLING ADDRESS <br /> BUSINESS NAME / PHONE# EXT- <br /> ? �7 833 -07 <br /> HOME Or MAILING ADDRESS p FAX/ <br /> ( ) <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent or same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HBALTN 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 and FEDERAL I <br /> APPLICANT'S SIGNATUR�� br DATE: <br /> (r <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/f MANAGER ❑ OTHER AUTIIORIZEDAGENT <br /> ILI- <br /> /f APPLICANT is not the BIWNG 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 HEALTH 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: 1.lS T pAYMEN <br /> _ COMMENTS: <br /> DEC �Z002 <br /> SAN JOADUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENREL HEALTH 0IV1910N <br /> APPROVED BY: EMPLOYEE#: R/_ q DATE: <br /> ASSIGNED TO: UO� /ue EMPLOYEE lt: ,gl� <br /> /�)7 DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: / �� PIE: �90� <br /> Fee Amount: ODS } Amount Paid S 7 OO Jv Payment Date 1213 f-0-;1— <br /> Payment Type Invoice ItCheck H j Received By: �- <br /> EHD 48-01-025 <br /> REVISED 6-55-0-0 2 SERVICE REQUEST FORM <br />