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4 <br />{ � j SAN.TOAQiCOUNTY ENViaR(3�NMENTAL HEALr*4,DEI'ARTMENT E <br /> REQUEST <br /> Type of BUsinesi or Property e FACILITY ID# SERVICE REQUEST# <br /> fd0d �prt boo 5 le <br /> 0 9! <br /> OWNER/OPERATO - — <br /> �` .DDRESS <br /> FACILrrY NAME - <br /> SITE ADDRESS. uF. <br /> Street Nvm6er Direction Zi Code <br /> HOME or MAILING ADDRESS (If Different from Sit' / f <br /> I <br /> CITY <br /> PHONE#I ExT. <br /> PHONE 02 EXT. � /�), u CODE <br /> CONT <br /> REQUESTOR p I / U� a� <br /> BUSINESS NAME l (t J �jv� y EXT.le <br /> �. <br /> l <br /> HOME or MAILING' <br /> Iao <br /> CITY O <br /> 4 ---'COO � .//rye <br /> 'BILLING ACKNOWLEDGEMENT: I, i tt-- 'r ent of same, <br /> acknowledge thAt all site and/or project spec this project or <br /> activity will be billed to me or my business T <br /> r ' <br /> I also certify that I have prepared this appli4 SAN JOAQUIN <br /> COUNTY Orrlinn`n` ce Codes,Standarris,STAI•i 9 <br /> e APPLICANT'S SIGNATURE: f 3 f <br /> i <br /> PROPERTY IBLISINESSOWNER❑ OPFIV 3 <br /> F P 999 <br /> if APPLICANT is not the BILLING PARTY,proojojnrrtherization 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 Bile address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment ' 1 <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at lh. ame time it is �• <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: o�G u�T,�6rL /(/1 E Sr&? G <br /> COMMENTS: <br /> SAN SO��p��N�py�N� <br /> APPROVED BY: I� EMPLOYEE#: DATE: Q7/2.� d3 k <br /> ASSIGNED TO: Ij � EMPLOYEE#: DATE: <br /> P i <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: �� T 00 Amount Paid ( SOO Payment Date Z4vh3 <br /> Payment Type 11 Invoice# Check# ` -7 Received By: } <br /> I <br /> EHD 48-01-025 ! SERVICE REQUEST FORM <br /> REVISED 6-5-02. a ' <br />