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SAN JOAQ*COUNTY ENVIRONMENTAL HEA* DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business Property FACILITY ID# SERVICE REQUEST# <br /> FA00C3 T33 C, <br /> OWNER/ OPERATOR !A' 1Wp1,(� <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME yam\yt I <br /> SITE ADORE <br /> Street Number Dimm <br /> on Street Nae mu Cir"t/�'� 1J <br /> � ZI Code <br /> HOME Or MAI NG ADDRESS (If DifJ@renI from ( Address) <br /> NI` ��(� Street Number Street Name <br /> CITY STAT —1% ZIP <br /> PHONE#1 EXT' TPN# LAND USE APPLICATION# <br /> PHONE# EXT. SOS DISTRICT LOCATION CODE <br /> c 5— � <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REO NMI' <br /> 1 <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME . PHONE - — EXT. <br /> 1�0 <br /> 61 <br /> HOME Or MAILING A D t SS U (4�) �& , 4 <br /> Ci�t+JC <br /> CIN STATE ZIP _ 70 <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 DEPARTMEN'r 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 Cor/es,Standard STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> , h � ( ' DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I MANAGER OTHER AUTHORIZED ACENT N( <br /> /f APPLICANT isnot the BALLING PARTY proof of nrlthorizatiou 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 HEAimi DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. N"T <br /> TYPE OF SERVICE REQUESTED: ST f-J r 1 t RECE�V <br /> COMMENTS: SEPCOUNTY <br /> P,LIOHEA HS RNOE SIGN <br /> ENVIHONMENTA�HEA <br /> APPROVED BY: EMPLOYEE#: 21 2 DATE: q - 10 03 <br /> ASSIGNED TO: v EMPLOYEE#: 8313 <br /> I DATE: q -(L) v.) <br /> Date Service Completed 4if already completed): SERVICE CODE: 1,19 PIE: <br /> Fee Amount: Amount Paid a7 cl Payment Date )D C-� <br /> Payment Type ✓ Invoice# Check# `75-7S Received By: <br /> EHD 48-01.025 SERVICE REQUEST F J L <br /> REVISED 6-5-02 <br />