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SAN JOAQUI*A UNTY ENVIRONMENTAL HEALTH , PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />CHECK If BILLING ADDRESS <br />SERVICE RE4UEST # <br />BUSINESS NAME 2 � <br />fCo.�FrricF/..� c4xdi-,,r <br />OWNER / OPERA T <br />CHECK If BILLING ADDRESS <br />e e <br />HOME or MAILING ADDRESS <br />JJ/�[. <br />FACILITY NAME ` iCo�402%4 <br />DATE: <br />SIMADDRESS /S � <br />E- <br />/e�A <br />%nfCIJ.pE/.T r7 'ry!/`. <br />S9 9 - 8 4s? <br />�LY.- <br />STATE C? <br />ZIP 6a$(-5, <br />rectl.n <br />Street Name <br />Payment Date <br />Ci <br />Zip Code <br />Invoice # <br />Check # <br />Received By: <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Nember <br />Street Name <br />CITY <br />—V 9iYI tom' — <br />STATE Zip <br />PHONE Ni Exr' <br />APN # <br />LAND USE APPLICATION # <br />(33o) o2S8 --2`►/"'� <br />PHONE $2 Exr. <br />- 3912 ) 1 <br />BOS DISTRICT <br />LOCATION CODE <br />(S(.2) <S9� x-2 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />�' <br />CHECK If BILLING ADDRESS <br />{IFjA�L u <br />i� <br />BUSINESS NAME 2 � <br />fCo.�FrricF/..� c4xdi-,,r <br />PHONE ii' <br />I Ij-&2 <br />i9 - 3 9 '7% <br />HOME or MAILING ADDRESS <br />FAX# <br />DATE: <br />Date Service Completed <br />(if already completed): <br />(' az) <br />S9 9 - 8 4s? <br />CITY <br />STATE C? <br />ZIP 6a$(-5, <br />,4 <br />Payment Date <br />BILLING ACKNOWLEDGEMENT: 1, 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: i`G Gc.X� _ v/ DATE: n9- � O - O /7/ <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER 13 OTHER AUTHORIZED AGENT iLdZdd&e-llO, <br />IJAPPLICANT 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 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: <br />�' <br />�.— 9 if <br />COMMENTS: <br />APPROVED BY: <br />EMPLOYEE#: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed <br />(if already completed): <br />SERVICE CODE: <br />P I E: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SERVICE REQUEST FORM <br />REVISED 6-5-02 <br />