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SAN JOAQUIN COUNTY ENVIRONNIM'iTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> o <br /> E5/ D gN r/.4 L R o <br /> OWNER/O1'1R,!5'# <br /> PERA�jTORI —^ (-syr <br /> `5`^ �,/ A AIF-7- J r •t r�4 CHECK if BILLING ADDRESS CI <br /> FACIUrY NAME <br /> SITE ADDRESS1� 7E COPr'EfZOpoL�s• STACK , <br /> Q / Street Number Direction ,•V� 5-F-5- <br /> J Z <br /> HOME Or MAILING ADDRESS (If Different from Site Address) Street Name Ci Zi Code <br /> Street Number Street Name <br /> CITY <br /> STATE Zip <br /> PHONE#tT• APN# LAND USE APP AT <br /> ( ) 63"- 252 ,vON <br /> PHONE#2 Ear. <br /> ( ) o V <br /> BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR— ID � /� <br /> Qr�r�/ LiCHECKIf BILLING ADDRESS <br /> BUSINESS NAME ' • PHONE# Exr. <br /> N uLTlGtioB— a <br /> HOME or MAILING AnPRESS FAX# <br /> P.0 x 3 ( ) 6g zs <br /> CITY STATE ZIP <br /> R�oG/� y e <br /> BILLING ACWOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that,Iall site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be bi"6d to me or my business as identified on this form. <br /> I also certify that ,have prepared this applic tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinande Codes,Standards,ST and FE DE laws. <br /> APPLICANT'S 4IGNATURE: Dare: <br /> PROPERTY/BUSINPASOWNER❑ OPERATOR/MANAGER O ER AUTHORIZED AGENT _ <br /> YAPPL/CANT is not the BILLING PAR Tr 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- JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or Ijy.representative. <br /> TYPE OF SERVICE REQUESTED: G(RFA l t,/BSGCRfA�F SDN rrfyNfFTjp/I/,�. y/�� <br /> COMMENTS: p� / <br /> RECEIVED <br /> JUL 21 2004 <br /> SAN JOAQUIN COUNTY <br /> _ CENVIRONMENTAL <br /> APPROVED BY: C)&t U+EI �a,.A EMPLOYEE#: � zj ATE: <br /> ASSIGNED TO: C_ '�-,C '�'t l/ 1 <br /> TTZ/' EMPLOYEE#: S(Z�L DATE: 2 <br /> Date Service Complgled (if already completed): SERVICE C/ODE: <br /> Fee Amount: '3 [S PI <br /> (e("CO Amount Paid C1-0 Payment Date <br /> Payment Type Invoice# Check# <br /> _. 1903 Jam:. Received By: <br /> EHD 48-01-025 <br /> REVISED 6-5-02 SERVICE REQUEST FORM <br />