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0A1N J UAQ WIN L,UUNTY L'N VIIWNNIENTAL 11EALIll DEPAKfNIENT <br />SERVICE REQUEST 0 <br />T e of Buslne§s or Properly <br />w7 FACILITY:ID # <br />1 <br />SERVICE REQUEST #;; <br />{t /I .,/� , <br />a sa'�¢'�V i i rc <br />v •,` /{'�� '`'7.'`$ y f t ;61 <br />O N,ER I OPERATVU <br />❑ <br />k A <br />STATE zip <br />CHECK If BILLING ADDRESS <br />FACILITY NAME i <br />EWwo <br />APPROVED BY _.. <br />n <br />SITE ADD SS <br />O/ <br />.. <br />DATE }! o <br />4�dt. <br />- <br />191521,9&de <br />Street NumberDirection <br />EMPLOYEE #C! <br />DATE: 1 +E f't+<lrr <br />a Name <br />'rl '44 <br />�' + <br />•. , LN 'F!?rX i +r'. <br />HOME or MAILING ADDRESS (If i r nt from Site Address) <br />(if already completed): <br />SERVICE CODE, <br />Street Number <br />Street Name <br />CITY <br />.4 <br />STATE zip <br />P NE 1 EXT, <br />30 <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 EXT• <br />B0SDIS- TII!1'9­T­-'0'- <br />r <br />W. <br />CONTRACTOR <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR- <br />CHECK If BILLING ADDRESS <br />1 <br />BUSINESS N E <br />^ <br />PON # _ ' <br />HOME Or MAILING ADDRESS ' , %/ o mi- <br />UV GC <br />FAX 4& <br />CITY ' <br />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 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, ST and FEDERAL laws. <br />e f <br />APPLICANT'S SIGNATURE: % ! / DATE: / / <br />PROPERTY / BUSINESS OWNER❑ 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 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 />wb 0 <br />COMMENTS: <br />` F P <br />SAN 10"'C"N SERu GE <br />PUWC14E�IjH P�j� DlV1�1�1t <br />EWwo <br />APPROVED BY _.. <br />, .. <br />EMPLOYEE # <br />.. <br />DATE }! o <br />i + <br />ASSIGNED TO: ­/1 <br />y�r ;ItJ <br />EMPLOYEE #C! <br />DATE: 1 +E f't+<lrr <br />'rl '44 <br />�' + <br />•. , LN 'F!?rX i +r'. <br />Date Service Completed <br />(if already completed): <br />SERVICE CODE, <br />.4 <br />Fee Amount:- <br />.Amount Paid <br />Payment Date <br />Payment Type I <br />Invoice#' <br />Check # Received By <br />EHD 48-01-025 <br />REVISED 6.5-02 <br />(� �LJSERVICE REQUWT FORM <br />