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S;tN JC IN COUNTY ENVIRONMENTAL I - <br />SERVICE REQUEST <br />mi DEPARTMENT <br />Type o[!usiness or Rroperty <br />I�C�r�� <br />3 <br />_ <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />SERVICE REQUEST # <br />C���,. <br />COMMENTS: <br />V U R--17�— <br />6 <br />CITY �/1 <br />6 o :; 10 <br />j ` <br />2003 <br />SEP 17COUNTY <br />n <br />SAN JOAQIN <br />PUBLIC H AUTH SERVICES <br />OWNER J OPERATOR <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS <br />EMPLOYEE #: -� �(j'� � <br />DATE: � <br />� ;CLQ <br />7L, <br />( 1 <br />CJJi <br />Street Number <br />Direction <br />$��(}.t��u <br />I (1 <br />,t <br />Zi Code <br />HOME or MAILING ADDRESS (If ifferent from Site Address) <br />Amount Paid <br />Payment Date <br />OLet Number <br /># <br />Street Name <br />CITY <br />T TE ZIP <br />)k nn'' <br />Ina—, <br />L 2' <br />PHONE #1 EXT. / <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 ]EXT. <br />C ),—(�� 3 <br />BOS DISTRICT <br />] <br />LOCATION CODE <br />CONTRACTOR It SERVICE RE,QUESTOR <br />REQUESTOR / <br />_ <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />G lc Q� ,nom <br />P NE# EXT. <br />), 4�v -C� 33 �- <br />HOME or MAILING ADQRESS <br />COMMENTS: <br />FAX# <br />CITY �/1 <br />STATE ZIP <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 />1 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, Standar* STATti-and FEDERAL laws. <br />APPLICANT'S SIGNATURE: /v II /� <br />A ",� � I" DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR / NIANACER ❑ O'rm,,R AUTlimuzrD AGENT <br />1j APPL (CANT 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 IiEALTII DEPARTML'NT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />} <br />TYPE OF SERVICE REQUESTED: S I (&f 1, 0 -1 1 <br />i\l lr <br />COMMENTS: <br />j ` <br />2003 <br />SEP 17COUNTY <br />SAN JOAQIN <br />PUBLIC H AUTH SERVICES <br />tNVIfiQNMFtI��` `+FALTI{DI�lISION <br />APPROVED BY: <br />EMPLOYEE #: -� �(j'� � <br />DATE: � <br />ASSIGNED TO: j, y <br />EMPLOYEE <br />DATE: <br />1 <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />I (1 <br />PIE: Z /`'• <br />Fee Amount:-� r, <br />Amount Paid <br />Payment Date <br />Payment Type LIZInvoice <br /># <br />Check It 0-2 <br />Received By: <br />EHD 48-01-025 SERVICE RNWEST FORM <br />RFEVISED 6-5-02 <br />