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SAN JOAQUIN LINTY ENVIRONMENTAL HEALTH EPARTMENT <br /> SERVICE REQUEST <br /> Ty"e of Business or Prop FACILITY l0# SERVICE REQUEST# <br /> K <br /> 0u S/ IF-, S R 003 0 40-7 <br /> OWNER/6PEBATOR <br /> � � f CHECK If BILLING ADDRESS <br /> �P/0FACILITY NAME <br /> Q Q <br /> SITE ADDRESS <br /> � <br /> / Street Number Direction I Street Name t'� Zi Cod <br /> I HOME or WAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( <br /> i <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CURE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQuR / G� 5—„o ?/ CHECK if BILLING ADDRESS <br /> BUSINESS _ PHONE# EXT. <br /> o 2 CT 7n <br /> HOME or MAILING ADDRESS FAX# <br /> t CITY STATE ZIP `' <br /> • 4� 7 C/ L <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 /> i 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 F ERAL laws- <br /> APPLICANT'S SIGNA DATA: - - <br /> PROPERTY/BUSINESS OWNER OPERATO /MANAGER OTHER AUTHORIZED AGE NT❑ <br /> # IfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> i <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: If r4e, <br /> COMMENTS: PAYMENT <br /> 4h1C4,A RECEIVED <br /> JUL 0 92902 <br /> /l SAN JOAQUA COUNTY <br /> NBUC HEALTH SERVICES9 0N <br /> 1 <br /> APPROVED BY: EMPLOYEE : DATE: -� <br /> ASSIGNED TO: EMPLOYEE#: D .I DATE: <br /> � I <br /> Date Service Completed (if already c ple#ed): SERVICE CODE: Z�” P!E. Z Go"I - <br /> Fee Amount: 4 4 Amount Paid �� Payment pate <br /> ► Payment Type Invoice# Check# Received By: <br /> END 48-01-025 SERVICE REQUEST FOR' <br /> REVISED 6-5-02 <br />