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SAN JOAQUli .,0U1 TY ENVIRONN, 1ENTAL HEAL DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR /� <br /> _ 'Aw <br /> LV yl l `�S GHECX if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESSO� �C I <br /> q <br /> Street Number Direction Street Name /Ci Zip Code <br /> HOME or MAI/LING ADDRESS (If Different from Site Address) l� 6 Gi(..IL ✓iL ' <br /> _ U� 1. �l/ Lel - / Street Number Street Name <br /> CITY � STAT ZJP C —Z U <br /> PHONE#I fir• APN# LAND USE APPLICATION# <br /> PHONE#2 Er. BOS DISTRICT - - LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTo p <br /> / �e 26 CHECK If BILLING ADDRESS <br /> 74 <br /> BUSINESS NAME ` PHONE# E= <br /> 11L,vl� oc . r 2L'-, I 53/ <br /> HOME or MAILING ADDRESS FAX# <br /> �- i 2 G') /J . --Sci Z ( '/�4, �C ( ) <br /> Cm �-G'G ; SrAr� ZP � Z`7c3 <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,Standar STATE and FERE laws. [, <br /> APPLICANT'S SIGNATURE: A�r� i-tti;� DATE' <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ (\ <br /> IJfAPPLfCANT is not the BILLINGPARTY proof of authorization to sign is required Title (x <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 soonas it is available and at the same time it is <br /> provided to me or my representative, <br /> TYPE OF SERVICE REQUESTED: 1.y <br /> COMMENTS: �C�•/�d — <br /> t v PAYMENT <br /> �. ( 8Jr6r.K DBwc lips } cD r�}cav ,rtcaoKi..l� I�l�+raKls RECEIVED <br /> C�n�i n lir rr ta.�� an few pw- , <br /> _ JUN 42Q02 <br /> SAN JOAQUIN CO'JNT� <br /> PUBLIC HEALTH SERVICES <br /> r APPROVED BY: (yaw <br /> EMPLOYEE#: <br /> ASSIGNED TO: --'64 ry EMPLOYEE#: TS DATE: Z _ <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> .. Fee Amount: Ft Amount Paid Payment Date <br /> Payment Type e A441 Invoice# Check# Received y: <br /> EHD 4MI-025 t SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />