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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT e <br /> r SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR _ <br /> CHECK If BILLING ADDRESS 0 <br /> �-'CUN-J Ul�(t�l;*-1. } ���_�`c.�-�. -)lyl`L i:_ l <br /> FACILITY NAME <br /> SITE ADDRESSrC.K..E=Trtti <br /> I'� 1�5SO <br /> Street Number Direction 3tmet AName city ZipCode <br /> HOME or MAILING ADDRESS (ifDifferentfrom Site Address) .\1� <br /> V'V\a`c>J cp Vic_ -�\ SJS /Street Number 1V �- ( - Street Name <br /> CITY STATE ZIP <br /> C-\ c152 us <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> n `i ) <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE "' <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR —tom - _ _ _ <br /> 4CA ( (S' .�;� I CHECK 1(BILLING ADDRESS <br /> BUSINESS NAME <br /> PHONE# Exr' <br /> X47 <br /> HOME Or MAILING ADDRESS FAx# <br /> CITY <br /> STATEa ZIP <br /> 9 <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,Standa S,STATE and FEDERAL laws. / C1 S'� -t{-Z i--f <br /> APPLICANT'S SIGNATURE: is' i (- l ��d n "-L l DATE: Z) Z <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT 11 <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: Qa 0 k e <br /> COMMENTS: RECEIVED <br /> AUG2 22002 <br /> PUBLIC HEEALTH SERVICES <br /> FNVIRONII tipkl HFAITH DIVISION <br /> APPROVED BY: EMPLOYEE#: L� DATE: <br /> ASSIGNED TO: EMPLOYEE#: 3 V 2 ( ::d <br /> DATE: Z7i•. L <br /> Date Service Completed,(if already ompleted): SERVICE CODE: 5 )--3 P I E: (QV j <br /> Fee Amount: "�(U`� Amount Paid Payment Date <br /> Payment Type Invoice# Check# - Received By: _ <br /> EHD 48-01-025 SERVICE REQUEST F( <br /> REVISED 6-5-02 <br />