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SAN JOAQUII' ")LINTY ENVIRONMENTAL HEALT- )EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 11M L 5�oo <br /> OWNERI 4ER kcc) CHECK If BILLING ADDRESS <br /> FACILITY NAME C� �n�, /,kt <br /> SITE ADDRESS (� <br /> Street Number I `Ruction R*Xf(y Skeet Na� G . Zip 2 2e <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY <br /> ElAf�„ /�� qNP 2 STATE ZIP <br /> PHONE#1 l (//� EXT. APN## o�- LAND USE APPLICATION# <br /> ) 1-3 --- <br /> PYHE 2 EXT. BOS DISTRICT LOCATION CODE <br /> /VF) ^ <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTO �/ ; <br /> flit/ CHECK If BILLING ADDRESS <br /> BUSINESS NAME � PHONE# EXT. <br /> HOME Or MAILING ADDRESS nen M-� , (AX# � 460 1 — <br /> CITY C//�V)l!XYJI ( STATE ; ZIP C�— <br /> B11,1ING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL 1-IEAum DF.PARTMEN'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 Colles,Standar IS <br /> STA"rid FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: / C� <br /> PROPFRTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTIIFIt At1TIIORIZFD AGENTIn-_�5kei., <br /> /? <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTFIORIZATION TO RELEASF, 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 env ironmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALI'I l 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: ;,C S j 9-*-Cr7.�0 1= C?— PAYMENT <br /> COMMENTS: <br /> SEP 212004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: L( V t EMPLOYEE#: �, Z / DATE: -�4 U <br /> ASSIGNED TO: ; r - ` EMPLOYEE#: r7 3 tC-) DATE: 2(f U <br /> Date Service Completed (if already completed): SERVICE CODE: �C� P I E: Z3,0 <br /> Fee Amount: ;)-7 4, C,O Amount Paid �'� Payment Date a D <br /> Payment Type / Invoice# Check# g eceived 6y: y/ <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />