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SAN JOAQUI*OUNTY ENVIRONMENTAL HEALTVEPARTMENT <br /> SERVICE REQUEST <br /> Type of siness or Pr perty FACILITY ID# SERVICE REQUEST# <br /> C;rL -r-A © &) 2 Sip 49 S ooh q j1 <br /> OWNER/O ETORS 2e <br /> CHECK if BILLING ADDRESS D <br /> i <br /> FACILITY NAME <br /> SITE ADDRESS <br /> / /�y <br /> C, Street Numberction �Dire (tn^/�r /-)�/J" &1 Street Name � �Cit '� Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> �) ��� Street Number Street Name <br /> CITY s STATE ZIP //11 <br /> 72 <br /> PH�QN�/E#1 _ EXT APN# LAND USE APPLICATION# <br /> (�[W ) `�/ V 5 L l <br /> PHO E\#2 J`C\J� EXT. BOS DISTRICT LOCATION CODE <br /> ( <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR I l —�� <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE �� / EXT. <br /> h, , C) — - 7 <br /> HOME Or MAILING ADDRESSJ (t I Fly q) i J& '7 .// <br /> CITY 117#241 p' STATE S< J ZIP <br /> BILLING ACKNOW EDGEMENT: 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 Codes,Stein dal. ', STATEPd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: � K.� '� <br /> DATtE�:� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLIC'ANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 /> COMMENTS: PA 's <br /> RC <br /> Au,21 ZW3 <br /> SANLtaNQum <br /> HS RNpV1S1UN <br /> APPROVED BY: EMPLOYEE#: L E0111N ATE: V :� <br /> ASSIGNED TO: EMPLOYEE#: � DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: iX P I E: Z 3 049 <br /> Fee Amount: a.� Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />