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SAN JOAQUIN'"OUNTY ENVIRONMENTAL HEALTH r EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS�! 3 (Q / , ,a �. 5 C/k <br /> Street Number I Direction W Street Name CI Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) q/:�( L--, S .j L4 Jjvt- V 5tc '290- 3 Z1 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> �l k 6 roves ' -1 <br /> PHONE#'1 EXT. APN# LAND USE APPLICATION# <br /> (416e ) 6 - Ce.l2-5- <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR t CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PH NE# EXT. <br /> `�l - 43C-- 130 <br /> HOME or MAILING ADDRESS FAX# <br /> 7j f'to �o(cl Pr, t'70 (`tt' ) lc3!" /317 <br /> CITY 4nG[d / ___/�� STATE G ZIP qS /76 <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 <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, STATE and FEDERAL laws.(—6 Y <br /> APPLICANT'S SIGNATURE: w 1tett DATE: Dllezloy <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT)a P^i/I <br /> IfAPPLLCANT 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 /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: PPA`1 VIEN <br /> COMMENTS: <br /> SEF $ 2004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: EMPLOYEE#: /J C/� DATE:: — 7 tl <br /> ASSIGNED TO: > I�,I / >,� EMPLOYEE#: F��7 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE:! L P!E: <br /> Fee.Amount: JAmount Paid 5 Payment Date 9 °(d Lr <br /> Payment Type Invoice# Check# 6 2� Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM' <br /> REVISED 6-5-02 <br />