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JAN JOAQUIN (-OUINTY LNVIRUNNIENTAL 11EAL1'H DEPAK"IWIENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# n SERVICE REQUEST# <br /> J 0�. � <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> -SITE ADDRESS W e 54 ��r7 c -s 4- <br /> c�I p ON E>o o- <br /> (7 <br /> i ., <br /> j� 7 1-5 / � Street Number Direction I` Street Name Ci icode <br /> HOME Or MAILING ADDRESS DWerent from :5-Sia Address) [ <br /> Z , g""-�'-'q <br /> 7 7 i5 !-fh Street Number Street Name <br /> CITY <br /> o J C zip ITS 3 3� <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 Err. BO DISTRICT LOCATION CODE <br /> t ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ <br /> X BUSINESS NAMEPHONE# ExT. <br /> -7-2E7�1 �L4 �eeK10 0 <br /> HOME Or MAILING ADDRESS 11 J FAX# <br /> l -:58 1 C7 S. ` 2�c��t pi (2 d 1 ) q1 8'�" 9 �0 f5- <br /> CITY <br /> CITY J �/ _ STATE zip 75-336 336 <br /> BILLING 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 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 /> XAPPLICANT'S SIGNATURE: DATE: Z `z►Z <br /> PROPERTY/BUSINESS OWNER❑ OPE R/MANAGER ❑ OTHER AUTHORIZED AGENT iJ ff <br /> If APPLICANT is not the BILLIN 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: S ( G we S-C,rCO) 01 1 1' lb,i re,,Po r <br /> COMMENTS: <br /> PAY M I- <br /> -/ RECEIVED <br /> JUL <br /> SAN JOAQUIN COUNTY <br /> rl PUBLIC HEALTH SERVICES <br /> APPROVED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: Qd t n O EMPLOYEE#. 3 vv�L�- DATE: -13 <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> EFAunt: Amount Paid Payment Date Type Invoice.# Check# Received By:`� <br /> EHD 48-01-025 SERVICE REQUE$X FORM <br /> REVISED 6-5-02 <br />