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JAN JUAVU1N I.DUN I L' NVIKONIVILN IAL HEAL H UL1'AK11V1LN 1 <br /> • SERVICE REQUEST <br /> Type ?Business Property FACILITY ID# SERVICE REQUEST# <br /> 7A� }=�Oo� 2321 SR Oo <br /> OWN /OPERATOR �e <br /> tCHECK if BILLING ADDRESS E] <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name CiyO/ ` NZip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 11 <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTO )� / CHECK if BILLING ADDRESS <br /> BUSINESS NAME pt1ON�C / EXT. <br /> HOME Or MAILING ADDRESS /�, .. FAx.# <br /> CITY TATE ZIP <br /> BILLING ACKN WLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTII 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: DATE: :9?7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTIIER AUTHORIZED AGENT LII / <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: U eA I Q f I PAYMENT <br /> COMMENTS: <br /> MAR 2 8 2003 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPROVED BY: EMPLOYEE#: Z Z �Z DATE: 3 - y <br /> ASSIGNED TO: S r ^_ EMPLOYEE#: © DATE: L�o — 3 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: -Z30 <br /> Fee Amount: Z� Amount Paid 1,- -7Payment Date 02 <br /> Payment Type ✓ Invoice# Check# /V— Receive By: eo <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />