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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST .n <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property <br /> t�' <br /> A�,e/e �4TURA� <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS JG 7}IAC - �L l/D QAC <br /> �� ��CC 1 y 9'�?77 <br /> 3( Street Number Direction Street Name Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> rO 11-EH Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICAn <br /> 409 9 A11,4 <br /> PHONE#2 Em. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> DivN <br /> BUSINESS NAME �NfuLT PHONE# <br /> HOME Of MAILINGADRESS ,Y FAX# <br /> V PC . 5ex 3 ( ) 66 9 -z59S <br /> CITY LQU STATE Cwt ZIP q,,,- <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledgetha' I site and/or project Specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project Or <br /> activity will be biped to me or my business as identified on this form <br /> I also certify thati 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,STATO�d FEDE w . <br /> i <br /> APPLICANT'S.$IGNATURE: DATE: <br /> PROPERTY/BUSINEAS OWNER❑ OPERATOR/MA AGER ❑ OT AUTHORIZED AGENT - <br /> If APPLICANT it not the BILLING PARTY proof of authoriz lion to sign is required Title <br /> AUTHORIZATIQN TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site addreV,� 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 representative. f r� <br /> TYPE OF SERVICE REaUESTED: IU FACS UBSu2FAG,E GnN err/NAT/&AJ £P012 tp I <br /> COMMENTS <br /> SSCrI, (DM "'o) JUL 19 2004 <br /> �IBIY' <br /> i <br /> t.tSAN JOAQUIN COUNTY <br /> pENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: L EMPLOYEE#: CT JI DATE: '7 / �} (� / <br /> ASSIGNED TO: - S EMPLOYEE M J L./5-7:, DATE: , ' I 0 C/ <br /> Date Service Completed (if already completed): SERVICECODEt: J?J PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />