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SAN ,J OAQUIr' 'JUN'1'Y LI'NVIILONNILN'I'AL I-ILAL' I)EI'ARTNIEWY <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 2 <br /> OWNER/ OPERATOR <br /> C-r(rCo�� C�� r,t C•/�/ CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> S / Slrect Number Olrecllon Street Name C/C city ZipCode <br /> NOME Or MAILING ADDRESS (If Different from Site Address) <br /> �' L ✓/ Slreel Number Street Name <br /> C ITY STATE Zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION N <br /> PHONE#2 EXT. DOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE RE, QUE <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> - <br /> BUSINESS NAME PHONE# EXT., <br /> � � ` � � �_ <br /> HOME or MAILING ADDRESS FAX If <br /> -33, <br /> CITY / l / STATE ZIP 5 <br /> ^£ (J L7J <br /> BIIAANG ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEAL'ni DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or lily 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,Standards,STATE and PEDE L laws. <br /> APPLICANT'S SIGNATURE: -�"� �/�C<�, �- DATE,: <br /> PROPL11TY/BUSINESS OIVN1iRl ' 011I:ItATOR/MANAGER ❑ 0-rnr.It AUTIIoitizirD AGLNT❑ <br /> If Al'PItCANC is not the B11.UNG PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INrORMA'I'ION: 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: f ^� f� PAYMENT <br /> RECEIVED <br /> 1 4 Y/U �vs»►� 0 /� L7' I� LG 2 t �V <br /> aAN OAOUIN COUNTY <br /> "UFL'C HEALTH SERVICES <br /> V I HFAI TH DM ON <br /> APPROVED BY: EMPLOYEE#: L/ DATE: <br /> ASSIGNED TO: O EMPLOYEE#: ! y DATE: <br /> Date Service Colnpllaf d (if airead completed): SERVICE CODE:/ P/E: <br /> Fee Amount: r ' Amount Paid Payment Date <br /> `ayment Type / Invoice# Check# lis Received By: <br /> 48-61-025 SE <br /> .ED 6-5.02 <br />