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SAN JOAQUIT�OUNTY EWiRbi MENTAL HEALT,-i?EPARTMENT <br /> SEkVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATO <br /> ^� CHECK if SICCING ADDRESS <br /> tf <br /> i `J <br /> f FACILITY NAME We <br /> of {` n i1L[ 1 � LC�n S <br /> SITE ADDRESS 7CM0 r l`c �`1�Ll V\ ���11�[ coi ` <br /> 4 <br /> Street Number Direclion Street Name t Zia Code <br /> HOME Or WILK:;ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY T �L STAT ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> F ( ) C? 3G- C5C67o a �- -b f+ -0 � 3 (S <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> F <br /> { ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR F �0 !1 eLv, J' e F /�`(f/�y4e it(o� d O sSoc �I'^ <br /> HQ , CHECK if BILLING ADDRESS E] <br /> BUSINESS NAME , r 1 PHONE EXT. <br /> vr9��son �- �s�c . �6�~a X75 <br /> HOME Or MAILING ADDRESS FAx# <br /> O )90C( <br /> CITY � ( STATE 00 <br /> Zip �( �r,0 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge khat all site and/or project specific ENVIRONMENTAL HrALTI-1 DEPARTmr-NT 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 Ihat 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,Stand Is,STAT a d FEDER I.laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPFRTY/BUSINESS OWNFR❑ I OPFItATOIt/ ANAGFR ❑ OTIIER AUTIIORIzFD AGENT❑ <br /> If APPt,1CANT 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTi-I DEPARTMENT as soon as it is available and at the same time it is <br /> Mprovided to we or my representative. <br /> TYPE OF SERV1f:E REQUESTED: 1 { QA+� Loci 4169 <br /> COMMENTS: —P t <br /> t 41U <br /> I J� i -t <br /> JUN 23 <br /> 4 <br /> :SAN JOAQUIN CO'JN TY <br /> 2rd pliBly'HEAL!H <br />` APPROVED SY: `"w EMPLOYEE#: -1:1 `L 1 J DATE: <br /> k ASSIGNED TO: EMPLOYEE#: Of <br /> el fq DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: f <br /> Fee Amount: S Amount Paid --- Payment Date '3/ 3 <br /> Payment Type Invoice# Check# Received 13y: <br /> EHD 48-01-025 SERVICE REQUEST.FORM <br /> t REVISED 5-5.02 <br />