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---�- ��5 <br /> SAN OA( N COUNTY ENVIRONMENTAL HEAL DEPARTMENT <br /> SERVICE REQUEST <br /> Type Business o Property FACILITY ID# SERVICE REQUEST# <br /> OWN /OPER�,�(�R <br /> �qR CHECK if BILLING ADDRESS E] <br /> J?) &C&CJ� <br /> FACILMkl4AME 12 <br /> 14L <br /> SITE ADDRESS (� _ Fii <br /> II StreetNumber DirectionName Cit15—e Co e <br /> HOME or MAILING ADDRESS (If Different from Site A cess) <br /> OStreet Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 / Exr. APN# LAND USE APPLICATION# <br /> (, �q ) p) <br /> PHONE#2 n ��J f _ Ext- BOS DISTRICT LOCATION CODE <br /> !01 CONTi RA.CTOR / SERVICE REQUESTOR <br /> REQUI r I/ !-::-t,X If P,:!LING AnDRESS <br /> B";iNESS NAM PHONE; / 2r�ExT. <br /> Ll4/�'i GL jL. �l��i _ _ Levi. <br /> Floe'E 1WtrlwLwG ADD t,:--SF <br /> F.ax# -- <br /> f <br /> I Y -- -- i / / e STATE ZIP <br /> — - <br /> BILLING ACIGVOWy, DGEi;':'t?' I. ...Id--. „ned -perty or `—t—Mess owiwr, operator or a th. iz^ri agcut of same, <br /> nc',nowledge that all site and/or project spec-i-:ENVHiONMENTAL HEALTH DEPARTMENT hourly charges associated with this projector <br /> activity will be billed to me or my busing:s dt,nh.;ed on this form. <br /> I alstz citify that I have p:'.p;.rai ul -p� ?-caocn and t,tat the work to be Ferfetmr d will K.-ct�c•ne in ai.coidan::e w:J,t ail SAN JOAQJIN <br /> C!�t.'tJTY Orciincr< ^odes,Stnndards, FEDE .la.vs. <br /> c <br /> APPLICANT'S SIGNATURE: C' DATE: q o23 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/NIANACER ❑ OTIIFR AUTHORIZFn AGENT <br /> If APPLICANT is not the BILLING 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 i-: available and at the same time it is <br /> provided to me or my represc:aa'ive. Q <br /> TYPE OF SERVICE REQUESTED— _ �'1 / f' ,d _ -- � �MENT <br /> COMMENTS: <br /> SEF 2 4 2004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: I EMPLOYEE#: q , r A'q DATE: <br /> ASSIGNED TO: 1/O/I �///� EMPLOYEE#: ���1 DATE: <br /> V i/ I �C ��yy <br /> Date Service Compldt d (if already Completed): SERVICE CODE: �U P I E: <br /> Fee.Amount: (JJ ".m�L!r t Opirl i onyme-# IIDatc- <br /> 1 ..DO —�L — — <br /> Payment Type Invoice# Check# g!� r] Pec.eived By: � <br /> EHD 48-01-025 L SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />