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OA1N .J"AV WIN l.UU1N 1 Y r.1N V 1KV1N1V1L'1N 1AU I11SAU1 r "E1rAK11V11;1N 1 <br /> ' A SERVICE REQUEST 0 <br /> Type RtPusiness or Pro e y FACILITY ID# SERVICE REQUEST# <br /> (-.ba - :[ 3 o-�5 Sit 0C 3 t 7C,(Z' <br /> OWNE /OPERATOR S� n <br /> YCHECK If BILLING ADDRESS❑ <br /> FACILITY NAMEU�Z „` /�;I� <br /> pmj <br /> SITE ADDRESS v7DI <br /> ( ( 0 <br /> Street Numrectian e N m it Zi Code <br /> HOME or MAILING ADDRE f Different from Site Addr s) <br /> V Street Number Street Name <br /> tr <br /> CITY STATE G V Z <br /> PH NE t EXT. APN# LAND USE APPLICATION# <br /> aa-t�,3�a3� <br /> (HONE) 77����3Exr. BOS DISTRICT LOCATION CODE <br /> 11 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOt Al htlU I M& -) - . - <br /> CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME I &6y PH N `e EXT. <br /> HOME Or MAILING DDRESS , f'X- FAX J ) 4- l <br /> CITY STATE ZIP <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 identified on this form. <br /> I also certify that I have prepared this appl'ca ion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST TE and FEDER41,laws. <br /> APPLICANT'S SIGNATURE: <br /> DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTIIER 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, 1, 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 /> A TYPE OF SERVICE REQUESTED: P' <br /> COMMENTS: RAYMENT <br /> REG�IVED <br /> NOV - 12002 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENAAL HEALTH D <br /> APPROVED BY: EMPLOYEE#: 1 6 DATE: <br /> ASSIGNED TO. EMPLOYEE#: � DATE: ' a� <br /> Date Service Completed (if already completed): SERVICE CODE: PA: <br /> Fee Amount: Amount Paid a &7 Payment Date f l D� <br /> Payment Type ✓ Invoice# Check# Received By: <br /> EHD 48-01-026 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />