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SAN JOAQUIN COUNTY ENv1RoNMW4TAL HEALTH DEPARTMENT <br /> �. SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# =SERVICEQUEST#ioy� <br /> OWNS /OPERATOR IFI)a CHECK if BILLING ADDRESS❑ <br /> do r <br /> FACLITY NAME <br /> SITE ADDRESS .t /. �� /PSf�j'{?y�0 g i <br /> 23,ZZ Street Number Dkectl n SVeet Name G ode <br /> HOME Of FILING ADD SS (If Different from Site Address) <br /> /��J C!/1 Street Number Street Name <br /> CITY /• STATE /'� ZIP <br /> PRONE#t Exr. APN# LAND USE APPLICATION# <br /> PHONER ET. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR e / CHECK If BILLING ADDRESS <br /> BUSINESS NAME / ;w v PHONE# '" <br /> HOME or MAILING(ADDDRREESS FAX# <br /> CITY �O / STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of sante, <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 will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: o� DATE: <br /> PROPERTY/BUSINESS OWNER 'OPERATOR/MANAGER EV OTHER AUTHORIZED AGENT 11 <br /> If APPUCANTisnotthe B/LL(NGPARTY 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 enviro ntal/site assessment <br /> information t0 the SAN JOAQUN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it LS availalll J t the same time it i5 <br /> provided to me or my representative. N v <br /> TYPE OF SERVICE REQUESTED: '�07 l <br /> COMMENTS: O 1 1��V \NGOV GE g�Ot" <br /> U "A_'lc-^ ^ a X47 <br /> APPROVED BY: USM EMPLOYEE M DATE: <br /> ASSIGNED TO: C� EMPLOYEE#: C DATE: <br /> Date Service Complet (if alreadycompleted): SERVICE CODE: Z - PIE: <br /> Fee Amount: / Amount Paid 14 �— Payment Date <br /> Payment Type ✓� Invoice# Check# 't23 Received W. ?yam_ <br /> EHD 48-01-025 SERVICE REQUEST FORM <br />