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01/13/2003 13:30 464013P. ENVIRONMENTAL HgALTH PAGE 02 <br /> SAN JOAQUI WC OLINTY LNVIRONMEN'I•AL HLALINWDEPARTML'NT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY-IDN SERVICE REQUEST 8 <br /> OWNER/OPERATOR <br /> CHECKII RILLINO ADDRESS <br /> ff <br /> FACILITY NAME <br /> SRE Moms t T 2 � k /J 61 W 'ir 7 cR• <br /> N un10N O 11 n Ire Nsme en I e <br /> HOME or MAILING ADDRESS (11 Different from Site Address) <br /> Slreel Number Simel Nome <br /> CITY STATE ZIP <br /> PHONE#1 . ErT• APNM LAND USE APPLICATION# <br /> PHONE#I EAT. SOS DISTRICT LDCAT oN CDOE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REOUESTOR CHECKII BILLING ADDRESS❑ <br /> 1 PFc <br /> BUSWESS NAME s�13 -Ge ez PxoNEN EeT• <br /> HOME amAig ADDR SS FAX# <br /> U CJ U' 124bq I Xq 83 <br /> CIT7$ *-„r.� STATFiin. .r TIP p d <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 DISPARTMENT 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 prepay ppliealion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY OrQin'a' Codes, a ., TATE and FEDERAL laws. <br /> APPLICA NT'S SI GNAT E: 6 Pit ` DATE: 07- a 9 O3 <br /> PROPERTY/DUSIN=. OWNER OPERATOR/MANAOeR ❑ On1rutAtmioluzeoAceNr0 <br /> /fAPPUCArrr it not the SIUJrve PARTY.proof of authorization to sign 0 required Titre <br /> AUTHORIZATION TO RELRASE TNFORMATIONt When applicable, 1, the owner or operator of the properly locatedat the <br /> above site addre%%, hereby authorize the release of any and all results, geotechnical data and/or environmeninl/site assessment <br /> information to the SAN JOAQUIN COUNTY CNvIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same (imc it is <br /> provided to me or my representative, N <br /> TYPE OF SERVICE REQUESTED: r� RECEI <br /> COMMENTS: <br /> tN COVIGE <br /> sPUB�ON�A THEA TH D1VIS10N <br /> ENNF•ONMENTAL <br /> APPROVED GY: — EMPLOYEE#: DATE: 3 <br /> ASSIGNEDTO: EMPLOYEE If: DATE: <br /> Date Service Completed (1l already comploted): SErrvicE CODE: PIE: <br /> Fee Amount: Amount Poid _ payment Date, -1 <br /> Payment Type Involce# Chock f D - Recoivod By: <br /> S6 SERVICE REQUEST FORM <br /> REVISED 6.5.03 <br />