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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -T <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESSC 9 r"—,) <br /> 'Z 57- ✓ Street Number Dlrect[on Street Name CIW Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) n/ ! 'ILT0,V aL I40 1 2-1' <br /> Street Number L Street Name J Z S,o — 7 Z J <br /> CITY STATE� C A 9 ZIP S'tl'Z <br /> PHONE 91 ExT. APN# LBOS <br /> SE APPLICATION# <br /> (y1g ) <br /> PHONIER ExT. ::�. STRICTLOCATION CODE <br /> CONTRACTOR CSERVICE REQUESTO <br /> REQUESTOR ��- 4% <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEe -Z- PHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> 3/190 �o�o L' PrP L�.e ,7�5 / ?ted (9/L )6 <br /> CITY � �0 �f'O'tz'6,4 STATE C,4 ZIP <br /> BILLING ACKNOWLEDGEMENT: 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 b performed wil be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. �6Y <br /> APPLICANT'S SIGNATURE: ✓� �'�zL DATE: D6117/°'1 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT '7' / !��✓d `�L <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 is available and at the same time it is <br /> provided to me or my representative. '( <br /> xJ <br /> TYPE OF SERVICE REQUESTED: T- a(C t/A L S j' -n1�_S pP� ��I%-1 <br /> COMMENTS: <br /> Qv�N <br /> sP�'okA <br /> APPROVED BY: C)L l U,C t EMPLOYEE MLnw 2_j DATE: y, <br /> ASSIGNED TO: (GS li EMPLOYEE#: �37,3 DATE: � �,2 �o <br /> Date Service Completed (if already completed): SERVICE CODE: Q 3 P/E: 02 3 < <br /> Fee Amount: ` �37_au !Z ±unt Paid 433 — Payment 6ate <br /> Payment Type r Invoice# Check# /WITReceived By <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />