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• .���,� �v���ui,� �.vuwtx 1L'.tvvltlVlvlvtL'lvt��Lx�Lt t11�UL1'AKA'1tilA�:[V'A <br /> W • '� <br /> [ SERVICE REQUEST l <br /> ti .Type of Buslne$s or Property, �r"�� '���;::FACIL•'ITY:IC#' - `�'�f,+Ar I •; SERVICE c. REQUEST'#,�,r �� <br /> Pe`i <br /> i e7 ! , <br /> OWNER/OPERATOR <br /> [ CHECK If BDDR <br /> ILLING AE$$El <br /> FACILITY NAME <br /> 1 SITE ADDRESS <br /> �` <br /> (reel NumberFolrectlonIr a1 <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> [.r„• •, C Street N Stted N:me � <br /> h ..... STATE ZIP <br /> PHONE#1 Ext. APN#, LAND USE APPLICATION# J <br /> PHONE#2 Exr• BOS'DISTRICT31 �';r�4y 'i�''�n ;t OCATION`CiOAtfIF� , <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR CHECK If 13ILLINo ADDRESS <br /> EIUSINESS NAME PHONE# ExT• 1',` <br /> HOME or MAILING ADDRESS Fax# <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 •H"�. <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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTi10RIZEDAGENT❑ <br /> If APPLIGfNr is not the BILLINC.PART. proof of authorization to sign is required rifle <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 andall 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: <br /> Y. <br /> Apk&ED BY: F.MPLOIIEE,#•.. [ <br /> J�• <br /> ASSIGNED T02' EMPL0EEt :.DATE.' ' <br /> Date Service Completed,(If already conipleted)7 SERYICE C <br /> .� r• .� viii;; •PIE. i <br /> �e <br /> 9-Amount:.:'. Amount Paid: <br /> Payment Date., i <br /> Paymont Type,' Invoice#; Y ,Check#.` <br /> Received By:� <br /> EHD 48-01.025. <br /> REVISED,Q.1.5-02 �� SERVICE REQt7WT FORM <br />