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F SAN JOAQUIN COUNTY ENVIRONMINTAL HEALTH DEPAATMENT � <br /> ;. <br /> 0 <br /> SERVICE Q�UEST <br /> Type of Business or Property FACII ITY ID'# SERVICE REQUEST# <br /> 0031930 <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> V I LTb12 EvDs-rA <br /> FACILITY NAME <br /> k <br /> r <br /> SITE.ADDRESS g�Zpf 1V Pb.DEsrA L-4, l E L.I/1D6V 95-236 <br /> I Street Number Direction Street Name 0tv Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> E <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> f!�') 0( q�O <br /> PHONE#2 EXT• BOS.DISTRICT LOCATION CODE' "",;: <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUES•TOR M j CHECK If BILLING ADDRESS <br /> i <br /> BUSINESS NAME PHONE# EXT' <br /> Dt n�uPpt1�l � 334-�i3 <br /> HOME or MAILING ADDRESS FAX# <br /> F 4 5:5P< 2180 (los ) 33¢- 0723 <br /> CITY LOO` STATE G� ZIP 95Z¢ <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 workt erformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE FEDERAL Ia <br /> APPLICANT'S SIGNATURE: <br /> DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ R ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT 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 Iocated 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: PAYN NT <br /> I RECLIVED <br /> f ie;� ` <br /> rkw4$t MAR 3 2003 <br /> SAN JOAQUIN COUNTY <br /> i [ PUBLIC HEALTH SERVICES <br /> APPROVED BY: EMPLOYEE$�: �� / DATE: 2 <br /> ASSIGNED TO: EMPLOYEE#: DATE: J <br /> Date Service Completed (if already completed): SERVICE CODE: 3 " P!E: <br /> Fee Amount: Amount Paid Payment Date 3 D <br /> Payment Type / Invoice# Check# �/ Received By: <br /> Ym Yp 5� �"t Y <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br /> R <br /> F <br />