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SAN JOAQUIN OUNTY L;NVIRONMLN'i'AL MALTSPEPAR'rmENT <br />SERVICE REQUEST <br />Type of Isiness orPrope ty <br />FACILITY ID # <br />o <br />BUSINESS NAME <br />SERVICE REQUEST # <br />5f ` , ; U <br />OWNER / 01311RATOR <br />HOME Or MAILING ADDRESS�� � <br />CHECK If BILLING ADDRESS❑ <br />FACILITY NAME <br />CITY 14, <br />i <br />S ZIP 1�65-� <br />SITE ADDRESS <br />Street NumberDirection <br />JAN 212003 <br />Name <br />SAN JOAOUIN COUNTY <br />ZI Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />APPROVED BY: �` <br />Street Name <br />CITY <br />" 1 TH D VI I N <br />STATE ZIP <br />PHONE #1 EXT. <br />f-0 ) <br />APN # <br />LAND USE APPLICATION # <br />PHONE///#2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />.P CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR j�I <br />! <br />CHECK If BILLING ADDRESS❑ <br />BUSINESS NAME <br />�p <br />PHO �xT' <br />_87 <br />HOME Or MAILING ADDRESS�� � <br />FAX � � ` / &3V -2f `/ten <br />CITY 14, <br />i <br />S ZIP 1�65-� <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 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 app 'cation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, E and FEDERAL laws.. <br />APPLICANT'S SIGNATURE: / t ; DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT <br />tf APPLICANT is Hot the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INI+ORMATION: 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. I <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />PAYM E N I <br />RECEIVED <br />JAN 212003 <br />SAN JOAOUIN COUNTY <br />PUBLIC HEALTH SERVICFS <br />APPROVED BY: �` <br />EMPLOYEE #:A <br />" 1 TH D VI I N <br />ASSIGNED TO: V r 1 <br />EMPLOYEE #: C <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE:I <br />i0 <br />P / E: <br />mountAmount <br />rPaey <br />Paid <br />— <br />Payment Date nn lent <br />Type <br />Invoice # <br />Check # 51 - <br />By: <br />EHD 48-01-025 SERVICE REQUEST FORM <br />REVISED 6-5-02 <br />