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L.. i <br /> - SAN JOAQUir?`�OUNTY ENVIRONMENTAL HEALTY"�EPARTMENT <br /> ` SERVICE REQUEST ' <br /> Type of Business or Property FACILITY ID# S RVICE REQUEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> Q �e hnn <br /> J <br /> FACILITY NAME n. 1 <br /> SITE AILL tour <br /> DDRESS u �(�9 12��' <br /> U O Street Number Direction "9I4f_ <br /> tr et"rA Ci` I ' Zip Code <br /> r HOME Or MAILING ADDRESS Alf Different from Site Address) <br /> UStreet Number Street Name <br /> Cl STA E IP <br /> PHONE#1 ExT' APN# LAND USE PLICATt0 # <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> I ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTO CHECK if BILLING ADDRESS <br /> BUSINESS NAME ,J PHONE# EXT.�t 11� - 3 <br /> HOME or MAILING AD 5FAX# <br /> � CITY � STT ZIP : <br /> f <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,Standar s STATE and FEDERAL lawns <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY BUSINESS OWNE,RV OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT 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 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: U A SNT <br /> COMMENTS: FL8" 4 nos <br /> '4N JOAQUIN <br /> ENVIRO <br /> I (//7��]/�ZCr CC,i.e rr C7 'moi/c �crCC HEAr�D,.p EWAL <br /> ell <br /> ACCEPTED BY' EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICECODE: P1 Z <br /> Fee Amount: Amount Paid Q Payment Date <br /> Payment Type Invoice# „-. Check#` _ Received By: <br /> RT <br /> EHD 48-02-025 r-. /rf�yRMrI/ <br /> REVISED 11/17/2003 �i°r f <br />