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j SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> i <br /> 0 SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#4 <br /> OWNER/OPERATOR <br /> ^� Sr(,vA CHECK If BILLING ADDRESS❑ <br /> FACILrrY NAME ✓V <br /> k <br /> SITE ADDRESS N. JAC9 7'DN45 AC444p0 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> r Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#1 ExT. APN# LAND U PLICATION# <br /> l <br /> PHONE#2 Exr. BOS DISTRICT LOCATION <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR } <br /> CHECK if BILLING ADDRESS <br /> I f <br /> BUSINESS NAME PHONE# ExT• <br /> T7i t t._otJ BVI urLP�-I 23 -66 r 3 <br /> P HOME or MAILING ADDRESS FAX# <br /> P o • r3�x Z I e,C> ( ZliA) 133¢-o7 z 3 <br /> CITY 0� ` STATE + L <br /> 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 application and that the work to be performed w' be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> DATE- <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is not the BILGING 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: <br />` COMMENTS: 7 PAYMENT <br /> 5 RECEIVED <br /> MAY 2 8 2004 <br /> SAN JOAQUIN COUNT`( <br /> ENVIRONMENTAL <br /> APPROVED 9Y: EMPLOYEE#: DATE: <br /> ASSIGNED TO: ° EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Ee,yeAmount: Amount Paid j . 6D Payment Date ' pment Type ✓ Invoice# Check# s'7(1(_ Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />