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SAN JOAQUI, OUNTY ENVIRONMENTAL HEAL'I )EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK if BILLING ADDRESS 0 <br />FACILITY ID # <br />7AJ- (Do 0 3 <br />SERVICE REQUEST # <br />OWNER I OPERATOR <br />PHONE # <br />S <br />CHECK if BILLING ADDRESS <br />FACILITY NAME ^ Y I i p <br />SITE ADDRESS 3 2 !'L <br />Street Number <br />Direction <br />C�1 I <br />O rn <br />Street Name <br />SI u� <br />ity <br />Zip Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />Date Service Completed (if already completed): <br />STATE ZIP <br />PHONE #1 <br />( ) <br />EXT. <br />APN # <br />Amount Paid <br />LAND USE APPLICATION # <br />PHONE#2 <br />( ) <br />EXT' <br />Invoice # <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE RE, QUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS 0 <br />C. � M- 44$- �� ce�tt.� <br />CEIVED <br />t. <br />BUSINESS NAME �1 — <br />PHONE # <br />S <br />ExT' <br />')S S� <br />_ <br />J _ VF o n1CTN C. <br />O' <br />HOME or MAILING ADDRESS <br />w�\' C� <br />FAX # <br />(S(.Q <br />)`4S3 - Sl(Ds <br />CITY (?„ \A%Ll- Q-A seg <br />ZIP or) &Y, <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, Standards, STATE FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT fR ate Q t- V— <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 environmentaUsite 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 />Drovided to me or my representative. <br />TYPE OF SERVICE REQUESTED: S I <br />PAYM <br />CEIVED <br />COMMENTS: <br />SEP 2 4 2003 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRON%1ENTA•L HEALTH D!VIS10P, <br />APPROVED BY: <br />EMPLOYEE #:; 'LZQ Z <br />V0 <br />DATE: _ 2� 0 <br />ASSIGNED TO: <br />EMPLOYEE #: '3 2 <br />DATE: —L4-03 <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: Q 8 <br />Fee Amount: 9 <br />Amount Paid <br />— <br />Payment Date Ol a O <br />Payment Type <br />Invoice # <br />Check # 3 <br />Received By: <br />EHD 48-01-025 <br />REVISED 6-5-02 <br />SERVICE REQUEST FORM <br />