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a <br /> _ SAN JUAQUIN (,"UN'.l'Y LNVIRONMLN'i'AL HLAL'1'H GI'Alt'I'MEN'T <br /> `�$ t ) SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> /6d 3 -)--7- 1 <br /> OWNER/OPERATOR <br /> f p L -fl 5Q CNECKif BILLING ADORESSC� <br /> FACILITY NAME <br /> SITE ADDRE S I-r <br /> 1-O D • __TBOG I Or. GC/5 <br /> 95� A'f v <br /> Street NumberT . Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY ! STATE Zip _ <br /> PHONE#1 E'n• APN# LAND USE P CATtO5ff / <br /> PHONE#Z EXT. BOS DISTRICT I OCATION CODE <br /> ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ! <br /> CnEcK if BILLING ADDRESS <br /> BUSINESS NAME r PHONE# EXT• <br /> , 3 -tl Grl <br /> HOME Or MAILING ADDRESS FAX# <br /> { } <br /> CITY STATE ZIP iJ <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,STATS and FGDERA .laws. <br /> APPLICANT'S SIGNATURE: ,i DATE::, � � O2 <br /> PuopwtTY I BusINESS OWNER❑ OPLzRATOR/M CL'It ❑ O-ruLit Atn toRIZED AGH NT tbt <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to Sibrtt 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, geolechnical 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: UPAYM E. <br /> 3 it i/ • - rxc RECEI D <br /> FEB 14 2003 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HSERVICES <br /> TAL HEAL H DIVISION. <br /> APPROVED BY: EMPLOYEE#: DATE: r / <br /> ASSIGNED TO: EMPLOYEE#: DATE. <br /> Date Service Completed (if already completed): SERVICE CODE: 3 P 1 E: <br /> Fee Amount: Amount Paid Zr>M' C Payment Date -; 1/ d-�5 <br /> Payment Type Invoice# Check# � g Received By: <br /> END 025 <br /> REVISEDSED 6-5-02 SERVICE REQUEST FORM <br />