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SAN JOAQU BOUNTY ENVIRONMENTAL HE, DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C<< 5�-O <br /> OWNER/ OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Y-\ to G <br /> FACILITY NAME `J\ a— <br /> SITE ADDRESS C\ci <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> (2ocil 'IA l8 ' 5's1 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME a PHONE# EXT. <br /> HOME or MAILING ADDRESS F # <br /> Iy 6 1 - G31I � <br /> CITY ` STATE2 CA ZIP C-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 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,Stands (IS STATE and FEDERAL laws. (� <br /> APPLICANT'S SIGNATURE: -6-9 <br /> DATE: �v _ <br /> PROPERTY/BUSINESS OWN Fit❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT v <br /> If APPLICANT is IOt t e BILLING P,I1TY 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 ENVIRONMEN-1-AL HEALTii DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. r <br /> TYPE OF SERVICE REQUESTED: U S ( fOLE'7-jL9-J -F J RECEIVED <br /> COMMENTS: SEP 3 'Z004 <br /> SAN JOAQUIN COUNT' <br /> ENVIRONMENTAL <br /> "EALTH DEPARTMENT <br /> APPROVED BY: L�(J tr t EMPLOYEE DATE: qWQ <br /> ASSIGNED TO: L-E_ EMPLOYEE#: J S 90 DATE: g `� <br /> Date Service Completed (if already completed): SERVICE CODE: 198 P I E:/ -23 p <br /> Fee Amount: r1 ,(J Amount Paid2 Payment Date 5 '0 q <br /> Payment Type Invoice # Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />