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SAN JOAQUWOUNTY ENVIRONMENTAL HEALS DEPARTMENT <br /> SERVICE REQUEST <br /> Typ f Business o PropFrEy FACILITY ID# SERVICE REQUEST# <br /> i FA 0010 , 39 SR 003398 ) <br /> OWNIUR I OPERATORCHECK if BILLING ADDRESS <br /> -11ML <br /> FA�CRRY NOM <br /> SITE ADDRESS /�(/(��' 7� , <br /> ' 1 J4 Street Number Oir dion to` StT!!t Name tN�ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site A dress) <br /> Slreel Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PH NE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEST • / CHECK if BILLING ADDRESS <br /> BUSINESS NAME r PHONE EXT. <br /> HOME Or MAIUdG ADDRESS r FAX# <br /> CITY STATE ZIP <br /> BILLING AC NOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMCNTALHEALTH DEPARTMEN-r hourly charges associated with this projector <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,ST and FEDERAL laws., <br /> APPLICANT'S SIGNATURE: ek�� /l VI [ WlJ _ DATE: <br /> PROPERTY/BLISINESSOWNERD OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ion Mitt �7 <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTITOR17.ATION 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 sante time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ET (e' rO if PAYMENT <br /> COMMENTS: <br /> MAY 2 8 2003 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTHSERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPROVED BY: EMPLOYEE#: 2LYj 2 DATE: . Z,P -03 <br /> ASSIGNED TO: tTvL F-O , „ EMPLOYEE#: DATE: ,S 2 J? —Q 3 <br /> Date Service Completed df already completed): SERVICE CODE: i $ PIE: 12_3 0,? <br /> Fee Amount: �(d-1 Amount Paid Payment Date d� O 3 <br /> Payment Type Invoice# Check# 7(: a Received By: k� <br /> EHD 48-01-025 SERVICE REQUEST FORJ� <br /> REVISED 6-5-02 <br />