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SAN JOAQULN C LINTY ENwRONINIENTAL HEALTH T'EPARTMENT <br /> SERVICE REQUEST VM' <br /> Type of Bu.`.iness or 9ropetty FACILITY ID# SERVICE REQUEST# <br /> r/0S�fa� � Us � <br /> OWNER/OPERATOR r CHECK if BILLING ADDRES <br /> G <br /> FACILITY NAME 1 j j <br /> SITE ADDRESS T�a/� Street Number Direction re)ztreet ame <br /> z� lo Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) Ale)2 .� )�/ � <br /> Street/Nu/ ber Cede t am <br /> CITY � _-� STATE <br /> ^ ,(J ZIP <br /> Cir"l <br /> rExT- APN# LAND US APPLICATION# _ <br /> PHONE#1 ..i A <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS❑ <br /> PHONE# ? ExT" <br /> BUSINESS NAME �� -' /� �� ( 2e C <br /> HOME Or MAILING ADDRESS S r-� � �� / „A� / j�/. �2#4 C2 � /_ <br /> / J// NNN /L.// STATE /�a'l, FZJIP <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 applicatio and that e work to be erformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE DE L laws. <br /> APPLICANT'S SIGNATURE: DATE: /� �/ 67 <br /> PROPERTY/BUSINESS OWNER❑ OP BATOR/MA CER ❑ 7- a <br /> R AUTHORIZED AGEN� �✓IJ T�'�C Tc� <br /> IfAPPLICAN of the ILLING PART proof of authoiott to sign is required Title <br /> AUTHORIZATION TO RELEAS INFORMA ION: 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: 2 /✓2 (� <br /> COMMENTS: <br /> Dt� " <br /> SAN JOAQUIN COUNTY <br /> EN�JiRONP R MENT <br /> APPROVED BY: D f't UE I�A EMPLOYEE#: D j Z 1 DATE: G <br /> ASSIGNED TO: ��V EMPLOYEE#: e,3'73 DATE: r 2— <br /> _(1,)/1J 2(� % <br /> Date Service Completed (if already omplet d'). SERVICE CODE: 03 c� g3 PIE: off. p 7 <br /> i <br /> Fee Amount: -/� c/ 00 =41 I 4�r. Amount Paid ,8, Urr� Payment Dae / A p <br /> Payment Type ✓ Invoice# Check# Received By: )� <br /> EHD 48-01-025 SERVICE REQUES- <br /> REVISED 6-5-02 <br /> r <br />