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I,1PA <br />ORVICE REQUEST 0 ff <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST <br />OWNER / OPERATOR <br />��✓C`L. L <br />®! t' � <br />CHECK if BILLING DMSJ13 <br />FACILITY NAME <br />Fax# <br />SITE ADDRESS <br />I <br />P 1 E: <br />/� Y G Gly. t -'gyp• <br />Amount Paid <br />s <br />S�Z a ' <br />Number <br />DirectIo[Ic <br />Received By: <br />- Street Name <br />C <br />ZJ2 Cod <br />HOME MAILING ADDRESS Different from <br />Site Address) <br />or (If <br />9/ ` <br />— 7 7 <br />Street Number <br />Street Name Z .ro - <br />CITY <br />CITY a,. vz:�2 <br />STATE ZIP 9 <br />PHONE #1EXT <br />(9/6 ) /1Z S <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 EXT. <br />BOS DISTRICT LOCATION CODE <br />REQUESTOR <br />/�- <br />CHECK If BILLING ADDRESS <br />BUSINESS NAMEPHONE <br />TT'G—CV- -' 64 n/ , V- C, <br />EMPLOYEE #: <br /># Exr' <br />//. /3, 1,9 <br />HOME or MAILING ADDRESS <br />EMPLOYEE #: <br />Fax# <br />CITY ,4jK..!"Cr O6V4 <br />STATE ZIP 9re <br />BILLING AC1KN ?t _WL E1191 : 1, 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 performed wil be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: �d"' �Z E DATE: <br />PROPERTY / BUSINEss OWNER® OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT iG dY / l ON•d d <br />IfAPPLiCANT 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 is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />APPROVED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P 1 E: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-01-025 SERVICE REQUEST FORM <br />REVISED 6-5-02 <br />