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i SAN JOAQUIN CQ '1'Y ENVIRONMLN'1'AL HEALTH 1" AK'1'MEN'1' <br /> SERVICE REQUEST <br /> `Type of Business or Property FACILI Y!�# <br /> i - SEi3VICi;REQUEST q • <br /> I �7 G; Q <br /> OWNER/OP RATOR 1ti / v <br /> f c>i la <br /> Qy- CNECKIfBILUN—gAuDRESS❑ <br /> FACILITY N11M>: <br /> F SITE ADDRESS _ <br /> r! 60 <br /> D Street Number0frectlon �� /Q� [..� <br /> HOME or MAILING ADDRESS It Di{fere [reef Name Clt <br /> ( nt from Slte Address) zI code. <br /> ----------------- <br /> F CITY Slrecl Number <br /> Strcel Name <br /> y STATE ZIP <br /> P Ext. <br /> PHONE#1 • <br /> ( 523 APN. it 9 ^ _ LAND USE AP LI ATIoN H <br /> PRONE#2 ext. _� <br /> ( ) <br /> SOSDISTRICT LOCATION CODE <br /> i� <br /> REour=sTOA CONTRACTOR/SERVICE REQUESTOR <br /> � ' <br /> CHECK It BILLING A0D ESS , <br /> BUSINESS NAME <br /> PHONE N EXT, <br /> Hom-or MAILING ADDRESS FAX# <br /> CITY Z /� <br /> [�O / STATE r ZIP O <br /> I31Li,1 G ACKNOWLEDGEMENT: 1, 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 We or 111Y business as identified on this form. <br /> I also certify that.l have prepared this application and that the work to be performed will be done in accordance <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws with all SAN JOAQUIN <br /> APPLICANT'S SIGNATURE: <br /> DATu: <br /> PROPERTY/BUSIN=OwNLIt❑ OPERATOR/MANAGER ❑ OTIIGR ALmlORIZED AGMT❑ <br /> 1f AppucANT is riot the BILLING PAR Y proof of authorization to sign is required Title <br /> A TI-I RiZATI N TO RELEA E INF RMATI N: When applicable, I, the owner.or operator of the property located at the <br /> above site address, hereby authorize the, rebase of any and all results, geotechnical data and/or environmental/site assessment <br /> in to thc,SAN JOAQUIN COUNTY LNVIRONMENTAt,HEALTH DEPARTMENT as soon as it is available and at the same time it is +E <br /> provided to me or my representative. <br /> TYRE OF$EAViCE REQUESTED: <br /> COMMENTS: C� / <br /> Y(/,; 2003 <br /> r <br /> . Et1VIR�N i <br /> APPROVED BY; ENipLOYtiE #: <br /> DATE: <br /> ASSIGNto'TO: <br /> rJ OCt G..C7s EMPLOYEI #: DATE: <br /> Date Service Completed (if already completed) <br /> SERVICE CODE: 31� P 1 E: <br /> Fee Amount: aD Amount Paid <br /> /,7 F, Payment Date <br /> Payment Typo Invoice# Check# 1 <br /> 4;4-( Received 8y;,-� <br /> EHD 4$-01-025 i <br /> REVISED 6-5-02 SERVICE REQUEST FORM <br />