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SAN JOAQUT COUNTY ENVIIZONMENTAL, HEA1;'- DEPARTMENT' <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> e) 0 3 s/ Z I <br /> ,bWNER I OPERATOR <br /> A;/n ( ff A <br /> FACILITY NAME CDVCHECK If BILLING ADDRESS <br /> �T15`�-'�•— '� J� <br /> SITE ADDRESS ASCO <br /> Direction Strr�r� �T � <br /> Street Number eet Name i Zi Code <br /> HOME Or MAI ING DDRESS (If Different from Site Ad cess) <br /> ` LE`f' Street Number Street Name <br /> CITY ( � $ m ZIP c( <br /> S733 -7 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ) � o�- � <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> EQUESTOR <br /> n-,a S6L, 7,G- <br /> ,G^� CHECK If BILLING ADDRESS <br /> BUSINESS NAME V`-,�lJ� �—f V�f V'— PHHONE# EXT. <br /> 1 a b - `/ <br /> HOME or MAILING ADDRESS FAX# <br /> CITY O n Q STATE ZIP <br /> BILII`,'ING ACKNOWI.,EDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTi-1 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 and FEDERAL IaAVS. <br /> APPLICANT'S SIGNATURE: L DATE: <br /> PIt01'Fivry/BUSINESS OWNER❑ OPERATOR/MANAGEit ❑ OTIIEIt AUTHORIZED AGENT� t�/J✓G f C� <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tide <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 ENVIRONMEN'T'AL HEALTH DEPARTME'N'T'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: p� <br /> COMMENTS: <br /> SAN 30µOI H S RV CES <br /> PUBLIC TA1 HEAITNOlVIS1pN <br /> i..NVIRONMEN <br /> APPROVED BY: EMPLOYEE#: � DATE: ! n 2 <br /> ASSIGNED TO: EMPLOYEE M DATE: ` �cJ <br /> Date Service Completed (if already completed): SERVICE CODE: 5-43 P 1 E: rG a/ <br /> Fee Amount: 4/0U Amount Paid ��7�' _ Payment Date �fr03 <br /> Payment Type ✓ Invoice# Check# �.�/ Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />