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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> "k4- SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> F,¢ OD03 ��21 sR�� 3os87 <br /> OWNER I OPERATOR CD O �wCtS CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME M <br /> SITE ADDRESS I{C-- -rLj( Z <br /> M)qA/ r <br /> 0 Street Number Direction Street Name cityZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr• APN# LAND USE APPLICATION# <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# Er. <br /> K E , Cull-T, s C s-r• a Zo Z3 zy <br /> HOME Or MAILING ADDRESS FAX# <br /> 1338 S, nn-uld ( ) <br /> CITY I ro STATE n ZIP ; 3 3 0 <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 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,StandardsS/TAT�and FEDERAL laws. ^� <br /> J <br /> APPLICANT'S SIGNATURE: I�r r•� 1 /A DATE: {�� � `//a 2- <br /> PROPERTY I BUSINESS OWN FR 11 OPERATOR/MANAGER 11 OTHER AUTHORIZED AGENT 4 pu),x, .JtE�-r, <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Titre <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: UST C�Qrnd I/G I PYM� D <br /> COMMENTS: R <br /> S Nil <br /> N RONM Na`�F E V10E gtOt` <br /> E <br /> APPROVED BY: '1 EMPLOYEE M �1 "�� DATE: 1�3 ri <br /> ASSIGNED TO: yn . J — - EMPLOYEE#: 3,S O DATE: •-,-3 `} <br /> Date Service Completed (if already completed): SERVICE CODE: Q-3 P I E: <br /> Fee Amount: C Amount Paid - Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> In <br /> EHD 48-01-025SERVICE REQUEST FORM <br /> REVISED 6502 <br />