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--. _ .. ,,1 .jl�vi.irl�ly 1 AL n>✓r�1 1 tl 1JEFAK 1 1V1.N:NT <br /> SERVICE REQUEST <br /> • Ty a of Business or Property16 <br /> FACILITY!D# <br /> �. SERVICE REQUEST# <br /> r/1000 <br /> OWNER/OPERATOR 3,so <br /> FACILITY NAME <br /> CHECK if BILLING ADDRESS O <br /> � <br /> SITE ADDRESS <br /> Street erDire tio� a� <br /> Street Name Cit <br /> HOME Or MAILING ADDRESS (If Different from Site Address) Zip Code <br /> Street Number <br /> CITY Street Name <br /> E ZIP <br /> PHONE#1 EXT. <br /> ( LAND USE APPLICATION# <br /> PHONE#2 ExT. <br /> ( ) BOS DISTRICT LOCATION CODE <br /> REQUESTOR <br /> CONTRACTOR/SERVICE REQUESTOR <br /> � - <br /> 1t�� <br /> CHjECKi,f�1,LLINGA,DDR,ES,S <br /> BUSINESS NAME . ' <br /> HOME or MAILING ADDRESS � FAx#CITY $TATEZ <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,Sta rds,STATE and FEDERAL ws. <br /> _ APPLICANT'S SIGNATURE: <br /> DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER D. THER AUTHORIZED AGENT❑ <br /> - -- - --- jfAPPLICANT is not theBffJ"GPARTY 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: , J R1104 <br /> ECEI <br /> CONMENTS: <br /> SEP 162009. <br /> INSANJORO PMEN07ALTy <br /> ENT <br /> ACCEPTED BY: tp( V,ef Ae-,O�-. EMPLOYEE <br /> J DATE: q -/ <br /> 70 <br /> ASSIGNED TO: ( ; EMPLOYEE#: (F/ <br /> J DATE: / <br /> Date Service Completed (if already completed): <br /> SERVICE CODE: q (7 PIE: <br /> Fee Amount: Amount Paid t5 <br /> ent e <br /> LA 5 — Payment Date q/ <br /> Pa b (Q <br /> Ym Type ✓ Invoice# Check# <br /> Z(o Received By: <br /> EHD 4&02-025 <br /> REVISED 11/17/2003 3 SF1_Qf{Iv( oldrJ ) <br />