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SAN JOAQ1"N COUNTY ENVIRONMENTAL HEAT "'t-I DEPARTMENT <br /> SCRV;ICE IZEQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OW ER/ OPERATOIR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS � ���`�� `t\ f� • ,.� �� ` U e,�`t] <br /> Street Number Direction Street Name f Cit 1 Zip Code <br /> HOME or MAILINGADDRESS (If Different from Site Address) <br /> •`�/ V�' ` Street Number Street Name <br /> I/ CITY \ STATE ZIP0,41 q <br /> PHONE#1 EXT. APN# LAND USE ION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION ODE <br /> CONTRACTOR / SE,RVICE REQUESTOR <br /> y REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> 7�\ BUSINESS NAME ^ PHONE# EXT. <br /> HOME or MAILING ADDRESS In <br /> FAX# <br /> CITY STATE ZIP } <br /> 1111.1.1NG ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent` of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTI i DHPARTMENT 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 1 have prepared this applicati I and that the work t be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standurr r, STA"Tfl a FEDEI A laws. l <br /> APPLICANT'S SIGNATURE: Vq DATE: <br /> PROI'ERTV/BuSINFSS OWNER❑ OPERA"roil/MANAGER OTIIFR AUTNORIZFn AGENT ❑ ,nom +1 <br /> if APPt.IC'ANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUT1IOR1ZA'1'10N TO RELEASE INE012MATION: 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 fiNVIRONMtiNTAL HEALTH DGPARTMI NT as soon as it is available and at the same time it is <br /> provided to me or my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: � �� /�j' R <br /> COMMENTS: JUL 5 L <br /> SANJOAQUINCQUNTY <br /> PUBLIC HEALTH SERVICES <br /> /�'! �ESL�•7?t� G��� ,%' p,� �=NVIRONMFNTAL HEALTH DIVISION <br /> l e-0. J-1 <br /> APPROVED BY: // EMPLOYEE#: O DATE: <br /> ASSIGNED TO: G` EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Lia P/E: <br /> Fee Amount: , 7 y Amount Paid -7 _ Payment Date <br /> Payment Type d/ Invoice# Check It g31, Received By:� <br /> EHD 48-01-025 SERVICE REQUES <br /> R17VISF0 6-5-02 <br />