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JAN JOAQUIN COUNTYLI,NVIZOD [ENTALHEALTH I)EPARTMENT <br /> SERVICE Ra.QUEST 11 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> g co() 30 % -7 y <br /> OWNER/ OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Directlon Street Name city Zia e <br /> HOME Orr MA GADDRESS (If Different from Site Address) <br /> �(/'/ ti//� /C J �L��ti Street Number Street Name <br /> CITY J /C�� '/j�TE <br /> /.ZIP L i <br /> 4PHONE#I EXT. APN LAND USE APPLICATION# <br /> PHONE#2 D En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �,-hL CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> HOME or MAILING ADDRESS FAx# <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 applic on and the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stnndar d ERAL laws. <br /> APPLICANT'S SIGNATURE: %�/ ��� DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/T'IANACER ❑ OTHER AUTHORIZED AGENT 11 <br /> IjAPPLICANT 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 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,i✓v '}'C..e �..IBJ S� -}t ' /�. .? G \V <br /> COMMENTS: <br /> oy/�csT�,s�s.�svS.E.�aT <br /> Fut_a<»rnc 4 ibarmr�zeeJ <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNEDTO: �` EMPLOYEE Cr DATE: <br /> Date Service Completed (if eady c6 pleted): SERVICE CODE: P 1 E: ���.�•, <br /> Amount Paid Payment Date <br /> Fee Amount: '� - <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />