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SAN JOAQUIN C -ry ENVIRONMENTAL HEALTH fARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � <br /> � 3 2 Stec:0 3's 3 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME Vc.6 <br /> © L <br /> SITE ADDRESS -19 y Be.n�fk a)i v� HO �t' iv <br /> Street Number Direction StreetNameI CiV I Zio Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CIN STATE Zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> C /(C C t/Z C� CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME �' �1 a l p! PHONE# EXT. <br /> - AUoS O'Oa' f S� <br /> HOME or MAILING ADDRESS FAX# <br /> w��,ti� A N E (S0 `�3 - 51(0S <br /> CITY STATE ZIP n� S <br /> A� %t ' CA C'ft <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE FEDERAL laws. q /� <br /> APPLICANT'S SIGNATURE: ++�� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT IR AV f l-y- <br /> If APPLICANT is 1101 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 environmentaUsite 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: PAYNAE <br /> RECEIVED <br /> SEP 2 4 ZN3 <br /> SAN JOAOt1IN COUNTY <br /> PUBLIC HEALTH SEMICES <br /> ENVIRONMENTAL HEALTH C!VISIO% <br /> APPROVED BY: EMPLOYEE -Q1 �Q� DATE: �y - O <br /> ASSIGNED TO: EMPLOYEE#: V U DATE: ({ Z y o3 <br /> Date Service Completed (if already Completed): SERVICE CODE: 1 PIE: <br /> —7 Fee Amount: �-'1�' Amount Paid Payment Date u /p V <br /> Payment Type Invoice# Check# // Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />