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,SAN JOAQUIN COUNTY L'NVIRONIviENI'AL l EAL H.1 EI"AKrMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# nSERVICE REQUEST# <br /> OWNER I PERATOR AIV <br /> bA r" - /I y CHECK If BILLING ADDRESS❑ <br /> (J r¢'j 7 !i <br /> FACILITY NAMEzzo <br /> ! <br /> SITE ADDRESSr� ,/O�f // W>5�P� .G <br /> Ci tl Code <br /> Street Humber plrection J�'(, Streel NamGej' ��� ��G <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> P/HONE#2 EXT• BOS DIjSTRICTLOCATION CODE b_ <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> -��;!e`� CHECK If BILLING ADDRESS <br /> BUSINEss NAME Qaam 4f ��z�� ' PHONE# i XT• <br /> HOME or MAILING ADDRESS FAX# <br /> CITY Zell, <br /> STATE 614- ZIP CSD <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,STAT FEDERAL laws. I p <br /> APPLICANT'S SIGNATURE: DATE: o T <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 2lr <br /> IfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is requir d rill, T <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 envizonmental/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: •S(/t F ut tA r. A t. la nS i(Al I p--I rep v lir <br /> COMMENTS: � E <br /> ?�;,L- �y�'-- o P ,CE\\JE� <br /> S p`�G��f1GEV1510N <br /> APPROVED EMPLOYEE#: ^'Z ZP1V%R DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: f � <br /> Date Service Completed (if already completed: SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> 1-19 t-' -- 0 Y <br /> t Payment Type Invoice# Check# 1 ' Received By: <br /> 'F <br /> EFID 48-01-025 ` SERVICE REQUEST�FORM <br /> REVISED 6-5-02 <br />