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... <br /> Z. <br /> o <br /> x <br /> rOWN <br /> SAN JOAQ U*OUNTY ENVIRONMENTAL HEALTAPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property C FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> ^� CHECK If BILLING ADDRESS <br /> Ee-o A/o L v N D l vN iE <br /> FACWTYNAME <br /> .SITE,ADD�D Stree!Number Dir 1 ���� Street �k <br /> ty <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 /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> +1 CHECK if BILLING ADDRESS <br /> BUSINESS NAME Tr C /4 n PH E# �' <br /> C c-L.-7 l 1 F 6SD `�T�—SSS— At D <br /> d% <br /> HOME Or MAILING ADDRESS F # ilk <br /> C b <br /> CITY TO 1� �` fes,/` C , c p STATE ZIP <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 <br /> or 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, ATE and FEDERAL aws. f k <br /> ? o/l 9Q ,nev�:e/L/,L <br /> APPLICANT'S SIGNATURE: DATE: 1�a�-u <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT f`1 a./N-y <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Evr <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: n/n pvC ✓l I " '( <br /> COMMENTS: U n tQC�l' a i <br /> v <br /> surtN <br /> gi �OPQVNME <br /> APPROVED BY: 0L i oE iA EMPLOYEE#: Q Z� DATE: q 3G OE <br /> ASSIGNED TO: L& EMPLOYEE#: 3s f-6 DATE: / 36 G <br /> Date Service Completed (if already completed): SERVICE CODE: 3 P 11E: <br /> Fee Amount: ,-)-7 c7,r c) Amount Paid Payment Date tf <br /> Payment Type ✓ Invoice# Check# tF [ Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />