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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE-REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ OPERATOR 1 2 A/T N� S A A /�";�/OA L 1 <br /> /y',�'T' V CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 167/0 :�141`i4E✓11 zo� <br /> Street Number Direction Street Name Ci 2i Code <br /> HOME or MAILING ADDRESS (If Different f`roml Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAN PLICATION# <br /> (Wo '10 A22 - . <br /> PHONE#2 EXT- BOS DISTRICT OtATION COB <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR l.,i ./}�� <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEj7 y t t „, + ,n� "/n y PHO 3 ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> 0 - I' OX 2/5o ( 26q ) '3'?4 y7Z3 <br /> CITY j��i STATE C4 zip G3) / <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 wil e in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPGICANTis 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 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: �� �ECE� <br /> r � 6 <br /> �}'" SAN JO�QUINENTAL <br /> 3oE STN DEPPTMENT <br /> NEA <br /> APPROVED BY: 0 L CvF I EMPLOYEE#: 0321 DATE: ( �� <br /> ASSIGNED TO: M i EMPLOYEE#: DATE: / <br /> Date Service Completed (if already completed): SERVICE CODE: /s P E: US <br /> Fee Amount: g Cc, Amount Paid �� �,� Payment Date (h b' y <br /> Payment Type Invoice# Check# 13q Received By:4(IL <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />