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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> ... SERVICE REQUEST <br /> rType of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �,c a�3 a�C-� <br /> OWNER I OPERATOR CHECK If BILLING ADDRES <br /> FACILITY NAME q 1/ <br /> -�% SITE ADDRESS STATE ROL�T� �r/� <br /> I� Street Number Direction F Street Name/Go Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) Zlf3D A �/vj57RpNG 5 T' <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> L y sso <br /> PHONE#I Ez APN# LAND USE APPLICNTION# <br /> -Z. I -zoo -3 L l <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR. _--' - <br /> REQ ESTOR CHECK If BILLING ADDRESS <br /> Al <br /> PHONE# Exr. <br /> BUSINESS z e)� <br /> U � l <br /> HOME Or MAILING ADDRESS FAx# <br /> ( 3-04 3 2 <br /> CITY1 I STATE IP <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 thisplication and that work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar STATE an EDE laws. —�— <br /> X APPLICANT'S SIGNATURE DATE: �1GtLy ZQ --2G�2 <br /> PROPERTY/BUSINESS OWN Rt MANAGER OTHER AUTHORIZED AGENT 11 <br /> If APPLICANT is not the LING 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. EN <br /> yv� \ <br /> TYPE OF SERVICE REQUESTED: - Q, L <br /> COMMENTS: 8 Q 6 K ril4yAft O/r Y`/P�b IL _ <br /> wcw GOVNjc <br /> p,/w' SQ�`O NQPS <br /> OIL, _ nh+ <br /> 1 pAw• <br /> 1,17 APPROVED BY: Y EMPLOYEE#: ^ DATE: 7 <br /> ASSIGNED TO: ex G EMPLOYEE /ter DATE: <br /> Date Service Conirpleted (if al*completed): SERVICE CGDE: _� P I E: � (j <br /> Fee Amount: -�-�-- �� Amount Paid :tom_ t] Payment Date <br /> Payment Type Invoice# Check# 4 p D V 5 3oi-- Received By: Z,l__ <br /> EHD 48-01-025 i SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />