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NAN JOAQUIN UOUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Cut=rt--t� T ►t- <br /> sTocu,� S� oZ <br /> OWNER I OPERATOR �^�J �y7 <br /> 5 I A-e-suct<S •\r I�C�� 1�"' CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME 5 <br /> 2 L1G��J(J ^�A^P <br /> SITEADDRESS �ZZ ^ 1W rU �-tJ� ya-pQ �T�°tT- 5 ��t-c�,ti 'j's,UZ <br /> Street NumberFDIrectlon Street Name CI ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) S� X �-I ��I�r <br /> Street Number /� treat Name <br /> CITY � r2HNC ISC.C� STATE ZIP <br /> C-P4G 413 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 2-411 - o zs('0 Zzg 3 ) -59 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> —0yV\ I l � Sr�r+� ,� CHECK if BILLING ADDRESS <br /> BUSINESS NAME 1 l J �-^"'1 PHONE# EXT. <br /> �crr rL,L 6-SI-1300 1 <br /> HOME or MAILING ADDRESS FAX# <br /> 31/40 6CLD 64WIP DP11kL 5uaY1-70 (`flb ) (31- /31 -7 <br /> CITY , I-yo <br /> � C.oec o � STATE r ZIP 7 n <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 <br /> or 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,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ��1G— �. DATE: O` LI-7103 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT f �2T A4✓}'"bsy-- <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <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: E I71 I D��L2-- fZL�f�/L �/}G/Li l RECE/VED <br /> COMMENTS: SEP 12 2003 <br /> SAN JOAQUIN COUNT`/ <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEAI.TH 0IVL41OIF, <br /> APPROVED 8Y: ' EMPLOYEE#: l -7 DATE: 2 <br /> ASSIGNED TO: EMPLOYEE#: c- DATE: <br /> L CV <br /> Date Service Completed (if alrea compl ted): SERVICE CODE:e�3 PIE: <br /> Fee Amount: Amount Paid Payment Date p <br /> Payment Type Invoice# Check# o?6' 4 Receiv d By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />