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SAN JOAQUI'-"'d^OUNTY ENVIRONMENTAL HEALT" 7EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property <br /> FACILITY ID# SERVICE REQUEST# <br /> C0�7�1E2C/f}L n a�3 '9S- <br /> OWNER/ OPERATOR <br /> R� W / TLt - �` F <br /> GADDRESS� <br /> FACILITY NAME <br /> A o S <br /> SITE8 /Ess <br /> / Street Number /I'7Qy! 337 <br /> Direction Slreel Name <br /> HOME or MAILING ADDRESS (If Different from Site Address) zl codeCITY reetumber A/ STATE PHONE#1 EXT. ;a <br /> APN# LAND US�PxICATION# <br /> I ) 599- 7/ S _ �/ - A <br /> PHONE#2 EXT. <br /> ( I BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE RE,QUESTOR <br /> REQUESTOR <br /> 0A C11E-!5-1VEV CHECKIf BILLING ADDRESS <br /> BUSINESS NAME �O L PHONE# EXT. <br /> HOME or MAILING ADDRESS O <br /> FAX# / <br /> ( ) (v <br /> CITY n L STATE GA zip <br /> ,C X38 <br /> BILLING ACICNOWI,EDGEMENT: 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 nae or my business as identified on this form. <br /> I also certify that I have prepared this applic ou and that the work to be perfolTned will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST E nd FEDE w . <br /> APPLICANT'S SIGNATURE: DATE: ��—3 <br /> PROPERTY/BUSINESSOWNERCI OPERATOR/ ANAGER ❑ OTI RAUTHORIZED AGENT <br /> If APPLICANT is DOt lite BILLING'PANTY proof ojnrrd�or atioa 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 /> informatich 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: 6�L SG a I3/✓ <br /> COMMENTS: /'/d//2/o3 ECEIVE® <br /> 410'"14411./ NOV 3 2003 <br /> SANT JOAQUIN COUNTy <br /> MENT <br /> HEALTH DEPARTu L <br /> APPROVED BY: i'VI, 17,3;j�6 X61 EMPLOYEE#: q1 15--7 DATE: ('� Q 7J F3 <br /> ASSIGNED TO: O �� EMPLOYEE#: q3 7Z{ DATE: ///o 03.. <br /> Date Service Completed (if already completed): SERVICE CODE: P I : Z(o p1 <br /> Fee Amount: <br /> 44+-4W_� 5 41V Amount Paid _. Payment Date `- <br /> Payment Type L/ _ Invoice# Check It Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />