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SANUflAQviN COUNTY EN J O.iVMENTXL ` EI A—L( .�JDTPXRTM=ENT <br /> SERVICE REQUEST J <br /> Type of Business or Property f kGlLil1 iD# S'ER�fIGEfEi [) ' <br /> : <br /> �C 1 lTZ f i <br /> OWNER I OPERATOR r farcCK If 131(-131(-LING AUpRESS trJ <br /> � M� o �— �v J -e s �1.� LE <br /> FACILITY NAME <br /> SITE ADDRESS �,U+�T �tc'.�1�T Li•n:� _fin: _� ( >� <br /> Street Number I Direction Street Name City i Zip Code <br /> i HOME or MAILING ADDRE=SS (If Different from Site Address) <br /> �C <br /> i �• � � Street Number Street Name <br /> i CITy-� I STATE ZIP <br /> 'Z c <br /> i PHONE#1 ExT• APN#. LAND USE APPLICATION# <br /> I <br /> PHONE#2 EXT. DDS t]1STRiGC t Q4ATf4U„.ODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTQR - <br /> CHECK if 81LLING ADDRESS <br /> t� 3C-k-'4 <br /> 1�C �- Z 1 C � 'V•tL. � <br /> BUSINESS NAMEPHONE# EXT. <br /> HOME or MAILING ADDRESS FAX#, c� p <br /> CITY ��C-;`� A ' �` � C1 � (�� STATE Z1P <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 DFPARTMLNT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> i I also certify that I have prepared this application and that the wort:to be performed will be done in accordance with all SAN JOAQUIN <br /> I l COUNTY Ordinance Codes,Standards,STATE�, ”' <br /> .DE ws <br /> APPLICANT'S SIGNATUR • 'tom DATE; <br /> PROPERTY/BUSINESS ONYNER OPERATOR/MANAGER OTH'RAUTHORIzED AGENT D <br /> I Cf f.(PPLICANT 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 DEPARTMEN'r as soon as it is available and at the same time it is <br /> provided to the or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> + hcis e T fl�n <br /> t f)rl (C' RECEIVEp <br /> r] <br /> AF?PRQSfER.6Y G tl ERIPLQYEE# k ATE <br /> 4. <br /> ©� <br /> �#SSIGNI Il TL) �� _ i✓MPLOYEE DATE <br /> To's 111: <br /> F <br /> C}ae Ser�Ifeetrrtptetodtf already compi,eted} St aYlre Gop6 P! <br /> >.,x. <br /> 1 fr�AnloUrlt ; E At1TAlirtt Ptc l �ltlfGtl ❑ tt~ 1 p <br /> Payment Type Involve <br /> = <br /> # C#Tecic'# RocotucE Bq <br /> .`'�S <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />• vl�'cP�'�!! ��=(�-- ��I 1�DCS: <br />