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/�`' 0" i <br /> SANJOQQUNTY ENVIRONMENTAL HEAL'I'H,aGI'AWI'MEN'1' <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 1D# SERVICE REQUEST# <br /> -T <br /> OWNER I OPERATOR <br /> p CHECK if L3ILLING ADDRESS <br /> I v. <br /> !"K (.�'-C..t <br /> FACILITY NAME <br /> SITE AnrDDD-7�RE S _ <br /> 1 J v <br /> Street Number Dir len Ate�1,0Name D rOG Cli I O� Tq I Co <br /> de <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY (.l STATE ZIP �— <br /> PHONE#7 EXT• APN# LAND USE P CATIO It <br /> PHONE#2 ExT• SOS DISTRICT LOCATION CODE <br /> E l <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR r CHECK If BILLING ADDRESS <br /> BUSINESS NAME v � PHONE# �� +���� ExT• <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY STATE zip <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,STATE and 1~EDERA .l <br /> ! aw . <br /> APPLICANT'S SIGNATURE: DATE <br /> : <br /> , O2 <br /> Pitot-rRTYI BUSINESS OWNER❑ OPERATOR IM cER ❑ OTIIFRAUTIIORIZEDAGIiN'r Ib1 <br /> If APPUCANT is not the 1311 ING 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: <br /> COMMENTS: PAYM E <br /> / alt /��. -crc RECEIVED <br /> C7 A FEB 14 2003 <br /> ;VilP SAN.IOAOUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENmRQNMFNTJWL HEALTH DIVISION <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: ( [ DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE; <br /> Fee Amount: Amount Paid Payment Date L" AV 17� 3 <br /> Payment Type / Invoice# Check# Received By: <br /> LHD 4"1.025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />