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SAN JOAQI ' COUNTY ENVIROk, 'AL HEAT I DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPE TOR + <br /> 12 ` <br /> `�a ' oil <br /> it , Q CHECK If BILLING ADORES <br /> FACILITY NAME I `(f <br /> SITE ADDRESS <br /> Street Number Direcl�ion vC) 1 Street Name C� City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) (/ �1J1 r 1 <br /> Street Number re—V IStrecl Name _ <br /> CITY Co /• STATE ^R ZIP 4—Z <br /> PIIONE#1 EXT. ApN# LAND USE APPLICATION# <br /> ( ) O - l 0 -0 57 P 6 -p <br /> PHONE#2 EXT. BOS DISTRIC� OCATION ODE <br /> L <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORC4 u )6&-) CHECK if BILLING ADDRESS <br /> U <br /> BUSINESS NAME PHONE# EXT. <br /> V�ILk X —"570 <br /> FAx <br /> HOME Or MAILING ADDRESS ^ D\ �� ( '# <br /> d C.w,. or ) 333 -� :�o <br /> CITY / M� STATE 0 kc} zip FJ —g� <br /> 13I1,1ING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL 11EALTtI DEPARTMGN-r 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Slantlards TATE a F L•RAL laws. <br /> �J 2 <br /> APPLICANT'S SIGNATURE: DATE�:/�L J <br /> PROPERTY/BUSINESSOWNER❑ OPERATOR/firANAGIEll ❑ OTIIFRAUTHORIZED AGENTL`'i <br /> If ADPL/CANT iS not the BILLING PARTY proof of authorization to sign is required Tidr <br /> AU'I'1IORIZATION 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 <br /> REQUESTED: -51,t <br /> COMMENTS: GVP10 sem/K CQ� CkYlJyh d sl coLt �S . 't C /O <br /> �EC��V EQ <br /> APPROVED BY: EMPLOYEE#: ` S O �Otd Q <br /> ASSIGNED TO: EMPLOYEE#: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: Amount Paid t'�bS G cam' Payment Date Z� <br /> Payment Type Invoice# Check# l f 6Received By: l <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />