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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # t <br />OWNER I OPERATOR(� u L <br />T\ � � t � Ir' U , CHEGK If BILLING ADDRESS ❑ <br />L�JUL , <br />FACILITY NAME <br />s <br />SITE ADDRESS �a1 <br />U\-, • l �T cr-To V� <br />Street Number Irectlon Street Nams C 4 (I ! CI Z C <br />HOME or MAILING ADDRESS (If Different from Site Address) I itt,101 I/JEHVIGET <br />CITY STATE ZIP <br />PHONE #1 EXT. APN # LAND USE APPLICATION # <br />(Pt9) c= U I <br />PHONE #Z EXT.BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQU ESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME 4PHONE#00 <br />ExT. <br />HOME or MAILING ADDRESS I <br />IAO (I C C w.� c, �' FAx 51&) <br />CITY \ ^ -) STATE C lJN ZIP c—y Zo / <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent (oJf 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, S E and DERAL laws. <br />APPLICANT'S SIGNATURE: DATE:,- <br />PROPERTY/ <br />ATE:,PROPERTY/ BUSINESS OWNER 13 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 available and at the same time it is <br />provided to me or my representative. A x j7 �t '1, -2t-11 /-^, ,r <br />TYPE OF SERVICE REQUESTED: r- P t T s/�%' 2 Z <br />pp,Y M E=N I_ <br />COMMENTS: <br />QD�A <br />OCT 200, <br />19 <br />7E%G;�. <br />SPIN JOAQUIN\'ONM COUNTY <br />/ <br />DEPARTMENT <br />APPROVED BY: L (� ` I 1`2EMPLOYEE <br />#: 3 Z <br />DATE: <br />S- <br />,'',LiSiGNED TO: L- _ <br />EMPLOYEE #: 3 <br />DATE: O <br />/3US� <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P / E: <br />Amount: 7 c �, <br />Amount Paid <br />b <br />Payment Date <br />1 b DS <br />Payment Type <br />Invoice # 13G� <br />Check # S p 2 <br />Received By: 1 <br />EHD 48-01-025 SERVICE REQUEST FORM <br />"""" F=D 6-5-02 <br />a/� <br />