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SAN JOAQUIN(=r)UNTY ENVIROINMEN'TAL HEALTH-TIEPARTMENT <br /> SERVICE REQUEST .� <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SRoa 300 ( <br /> OWNER I PPERATOR CHECK if BILLING ADDRESS❑ <br /> (fir,e <br /> FACILITY NAME / G <br /> SITE ADDRESS Lq+� -/�Z3� <br /> Q^/ � feet Nam Ci Zi Code <br /> If F5 / Street Number (rection <br /> HOM�o r MAILING ADDRESS (If Different from Site ddress) <br /> �tlo1� �• ' rhe Street Number Street Name <br /> CITY STATE ZIP�C <br /> PHONE#1 E' . API/#0,5- ��/� O� LAND USE APPLICATION <br /> PHONE#2 Ex . BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I I.JNfA S v r CHECK If BILLING ADDRESS. <br /> 7 1 ` <br /> PHONE yam' <br /> BUSINESS NAME U 334--(ec, <br /> 1 lV• <br /> HOME or MAIL( ADDRESS FAx# <br /> Cirr LOt)I STAT` „ ZIP cl SZ <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,S n s,STATE and FED&RIAL <br /> /laaws. ^7 <br /> APPLICANT'S SIGNATURE: (fes DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ �PUIL Z�c�`✓� <br /> IfAPPLICAN is the BlLLINGPARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO LEASE 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: -5r-, 1 <br /> COMMEMS: <br /> PAY' EN roti <br /> RF=CEIVEC �tM ' 04 <br /> 0 N JOAOI(IFI i, iVT`, �OL <br /> 3 NVIROrAlf f BLICt' <br /> APPROVED BY: l/Jl EMPLOYEE#: DATE: <br /> ASSIGNED TO: t EMPLOYEE#: D ` DATE: <br /> EAun <br /> omplete (if already completed): SERVICE CODE:SC �'j_ P I E:� .O <br /> Amount Paid - j 7b%,L`a✓ Payment Date i ?._ <br /> Invoice# Check# 4t3,j Received By: `y <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 65-02 <br />