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SAN JOAQUINJQOUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type usiness or Property FACILITY ID# SERVICE REQUEST# <br /> � Sado 3 0� 3 S <br /> O. OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE AnDRE S <br /> C l./ Street Number Direction tNilfis <br /> HOME MAILING ADDRESS If Different from Site Address) <br /> (� <br /> Cl Stroet Number Street Name <br /> ATEp/ <br /> PHONE#'I APP{# LAND USE APPLICATION# <br /> - 7(a //79 �/ . <br /> PHONE#T / 6 3 - y �. BOS DISTRICT LOCATION CODE <br /> L/1 <br /> L.6/ <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR n <br /> Eke CHEC j ILLING ADDRESS <br /> BUSINESS NAME PHONE Exr <br /> HOME Or MAILING ADDRESS? FAX# <br /> c ( , <br /> CITY S oC STATE In ,^ ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agentofsame, <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,Standards and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: F DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> IJfAPPLICANT is not the BILLING PARTY proof ojauthorization to sign is required Trete <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 SEjE REQUESTED: 't1^ b a I n <br /> COMMENrs: J V 2 <br /> 9 200 . � 4/7wi 96 9/6zwL <br /> fAYNIEN i <br /> C � QwJG ,,aA~a RECEIVED <br /> 1 '�' 3Q A o JUL2 62092 r <br /> aAN JOAQUIN COUNTY <br /> APPROVED BY: ,I <br /> EMPLOYEE#: 2'L9Z ,ri1;P .A, I1q�yc gtiT„/ y�4 /:. <br /> ASSIGNED TO: EMPLOYEE M Q { �(4 DATE: 1 . /-L I j . <br /> Date Service Completed if already completed): SERVICE CODE: S' 1 PIE: 2.6 Z <br /> Fee Amount: d S� Amount Paid c�— _. Date a <br /> Payment Type �.- Invoice# Check# r 4Paymenl <br /> �� Received By: <br /> EHD 48-01-025 <br /> REVISED 6-5-02 SERVICE REQUEST FORM <br />