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SAN JW QUIN COUNTY E "RONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> cp5Y <br /> ` / <br /> I <br /> —' <br /> E � n` /V AMU_ 1TFS CHECK if BILLING ADDRESS <br /> FACILITY NAME v <br /> SITE ADDRESS �S 7c.% 7—PE-r74 �v-/AT- je l- 4 L o�i 9 5-210 <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) IL4 34 5 TN. 14 vvy rJ.., <br /> Street Number Street Name <br /> CITY L v0 STATE C d H ZIP 01`_T 4o <br /> ; <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( 21J I) 52 -600 2oo - 3 3 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR A A ' <br /> /v` I CHECK If BILLING ADDRESS <br /> BUSINESS NAME 1�oN ,�^J/A n�f^� PH � 3� -�/ 3 EXT. <br /> ( loHOME or MAILING ADDRESS FAX# <br /> t� o aox ZtE:ou (Lo, ) -33,{ - 07z3 <br /> CITY 0 / STATE C_4 ZIP p S Z4 ) <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 perfo A,will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, S14TE and FEDERAL laws. <br /> APPLICANT'S SIGNAT DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATORAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is 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: SL , <br /> COMMENTS: <br /> MAY <br /> 00� <br /> SAN't(-,,-tJIN'Co <br /> �I ?U('I :LTH SERVIC <br /> Fq <br /> APPROVED BY: EMPLOYEE#: / DATE: r It <br /> ASSIGNED TO: \ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed):/ SERVICE CODE: r' P I E. 6 <br /> Fee Amount: Amount Paid g Payment Date / <br /> Payment Type >/ Invoice# Check# /V 601 _ Received y: e <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />