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SAN,JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST 1 <br /> Type of Business or Property .FACILITY Iia# SERVICE REQUEST ; <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS❑ <br /> ,o r <br /> I <br /> fAcw NAME <br /> & E ADDS SST wL �6G�' g5240 <br /> Street Number Dlreetion Street Name Ci ZiCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> I <br /> I Street Number Streel Name <br /> I CITY STATE ZI <br /> 0L <br /> PHONE#t Err. APNi# LAAD USE APPLICATION# <br /> ( ) D63C �o:31 1 pr 79 2 <br /> I PHONE#2 Exr. BOS D15TRICT % MSE 4 LOCATION Co <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUE$TOR CHECK If BILLING ADDRESS <br /> PHONE# EXT. <br /> BUSINESS NAME S© ~ <br /> F <br /> HOME or MAIbNb ADDRES FAX# <br /> ! CITY 5T TE ZIP <br /> 21412 <br /> I ' <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 /> 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,ST TEan�FEDERAL laws. <br /> SIGNATURE: �" ` cl f DATE: <br /> APPLICANT'S <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANTis not the BILLING GPARTY,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 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: <br /> COMMENTS: e AYMENT <br /> n RECEIVED <br /> AUG 2 12602 <br /> �p0.1 i SAN J GOONEY <br /> HEALTH <br /> i � ��* �Ct/•+)' PUBLIC HEATH SERVICES <br /> APPROVED BY'. EMPLOYEE#: ,w <br /> DATE: " <br /> F <br /> EMPLOYEE# DATE <br /> I ASSIGNED TO: .>. <br /> Date Service Comp o ed (If alread ompleted): SERVICE CODE: P!E (� <br /> Fee Amount: Amount Paid Payment Date <br /> . .s <br /> Payment Type Invoice# Check# - Received By: <br /> yp „/� . <br /> EHD 46-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 I <br />