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SAN JOAQI 7UN1'Y ENVIRONMENTAL HEA0%EPARTMEN'1' <br /> SERVICE REQUEST <br /> ---Tf/4 qb5-7 5�2�3cl <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ OPERATOR <br /> C` CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> S , -T , Sec� v � � es <br /> SITE ADDRESS 19 X11 r1G v <br /> Street Number Direction Street Name Cit Zip 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 /> (9A c �13 - �66 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE RE, QUESTOR <br /> REQUESTOR <br /> C` �\, CHECK If BILLING ADDRESS 12 <br /> BUSINESS NAME i� PHONE# EXT.Li <br /> HOME or MAILING ADDRESS FAX# <br /> � 35 6WI (A 63'12 <br /> CITY G Oclq STATE C <br /> C ZIP 9 `2 O - <br /> I 11,1ANG ACKNOWI,EDGF,MENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HGALTH 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,Stnn1lLLlNGPA1—?TY <br /> STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ` � DATE: `1 <br /> PROPERTY/BUSINESS OWNER 11. PERATOR/MANAGER ❑ OTHE►t AUTIIORIZED AGENT <br /> !f fI PN/./CiINT is proof of nrr!/rnrlZatlon to sign is required Title <br /> AUTI-I0RIZATI0N TO REI,F,ASF, 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 ENVIRONMEN-rAL HEALTH DEPARTMEN'r 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. Gj( ECENED <br /> COMMENTS: 3 U 200 <br /> SAN JOAOUIN COUNTY <br /> VAL <br /> F{EpLTH DEPAR MENT <br /> APPROVED BY: G�L t vd�r2 EMPLOYEE#:�/J3u DATE: s'- `� )y <br /> ASSIGNED TO: EMPLOYEE#: (f DATE: <br /> ,914Ck 4-121N,Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />