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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> I C..gLI <br /> FACILITY NAME <br /> aAkr , At-19n, <br /> SITE ADDRESS N, -- b 2 $1 c c Ta s <br /> ` V u Street Number Direction Street Name Ci Zi Coda <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> ( I <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR n CHECK If BILLING ADDRESS <br /> O q (� �-1 v+C N <br /> BUSINESS NAME 'l _ PHONE# Exr. <br /> 13 9q�- <br /> 3912 <br /> HOME or MAILING ADDRESSFAX# <br /> 1 IctO W . t t, w ?A Ss Q o # ( 1 <br /> CITY C6 >` l Z,^-P STATE C� ZIP ci iti 1� <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,Stand:�M <br /> ws. <br /> APPLICANT'S SIGNATURE: DATE: 6s�%�7(O 9 <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/MANAGER ❑ OTHER AUTHORIZED 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 t0 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. RAvMENT <br /> TYPE OF SERVICE REQUESTED: RECEIVED <br /> COMMENTS: V C Z MAY 2 7 2004 <br /> oti` QL rA�rtv Q'ticA' <br /> SFE S G� J S 11�9 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: EMPLOYEE#: C) f DATE: --/-2-7/64 <br /> ASSIGNED TO: EMPLOYEE#: 2-S DATE: t" ^7 <br /> Date Service Completed (if already completed): SERVICE CODE: /C? P E: o d <br /> Fee Amount: Amount Paid I;,Z q. DZ Payment Date a7(0 L( <br /> Payment Type ✓ Invoice# Check# n-33 Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />