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{ <br /> SAN.T()AQ COUNTY ENVIRONMENTAL HEAT`—''T DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property <br /> fAClkffY la# SERVICE REQUEST# <br /> Ot�IfMER Ol'ERATDR C.•�' C 9913 <br /> F <br /> CHECK if BILL INGA DRESS :- <br /> FAcam WE <br /> SrrE ADDRESS <br /> Slroee!Number Dlreetia Street Na r <br /> HOME Or WANG ADDRESS Of tfliffemnt from Site Address) zi e <br /> A <br /> CITY Street NLynbef Str@P4 Name <br /> A ZIP <br /> PHONE#1 ' ExT APN <br /> s t LAND 1U5E APPLICATION# <br /> PRONO2 Eicr, ' <br /> { ) SOS D1$1McT LocAm CODe <br /> t <br /> -CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR �r` - �� <br /> ' !'I^! CHECK I€81Lu_NG ADDRESS Lem <br /> BUSINESS NAME <br /> (Z- # Eur. <br /> HOME or MAILING ADDRESS PHONE <br /> 15 FAX# , <br /> CITY STATE ZIP <br /> 4�5- <br /> j' <br /> BILLING ACKNOWLEDGEMENT— I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to we or my business as identified on this fbrm <br /> I also certify that I have prepared this applica and that the work to be performed will be done in.accordance with all SAN JOAQuiN <br /> CAoNTY Ordinance Codes,Standards,ST and T'ED$RAL <br /> APPLICANT'S SIGNATTM; <br /> DATE: f <br /> PROPERTY/BUSINESS OWNERO OPERATOR/MANAGER 0 OrBER AIrMORUMD AGENT O <br /> If APPLIC Tis.not the B17 uNG PARTY proof of authorization:to sign.is required Tt of e <br /> AUTHORIZATION TO RELEASE INFORM A TI`E}N: When applicable,t 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 COUN'ry.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 SERME REQUESTED: <br /> COMMENTS? <br /> l <br /> 2 7 ZZ07 <br /> { f <br /> NT <br /> �N 3gAQL3M COUi3n <br /> EN. oEPAF1'iW <br /> tiEAL <br /> Acc:PTSD$Y: If'J1 <br /> EMPLOYE DATE: D <br /> ASSIGNED TO: EMPLOYEE#: DATE' <br /> Date Service Completed (if already completed) SEME CODE: P 1 E: <br /> Fee Amount' <br /> Amount Paid <br /> ( Payment Date <br /> Payment Type ,. invoice# Check# Received By. <br /> .. <br />