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SAN ,IOAQUIP 'OUNTY ENVIRONMENTAL HEALT EI'ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDR SS �� <br /> f'aN � � <br /> CJ C ��Y� <br /> Slrect Number Fire,,ij � ( � Street Name d Zi 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 /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> OK <br /> BUSINESS NAME ` PHONE# EXT. <br /> r <br /> Erly 1 rOn e4%ftl- /1 t r�ee/r � ac <br /> HOME or MAILING ADDR S FAX# <br /> CITY /L _ _ AT !�z 7 O S <br /> BILLING ACICNOWLEDGEMENT: 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 performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Cortes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: /4ZZJ4=��— DATE: �( /,�/03 <br /> PROPERTY/BUSINESS OwNEIt❑ OPERAT46 MANAGER ❑ OTIIFR AUTIIORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tille <br /> AUTHORIZA"TION 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 /> informatiotl to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available ancl�tnt�tT same time it is <br /> m <br /> provided to e or my representative. PAYS ���`l'D <br /> TYPE OF SERVICE REQUESTED: R `' <br /> COMMENTS: <br /> SA�N�p�PPR MEN? <br /> H&CTN <br /> APPROVED BY: EMPLOYEE#: y DATE: f l r3 <br /> ASSIGNED TO: _�^ EMPLOYEE#: DATE: / 3 <br /> Date Service Completed (if already completed): SERVICE CODE: Oto r I Igo <br /> ( P t E: <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 />