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3A1N JOA(111-11i)i I.OUINA Y L'INVIKOINIV1LIN IAL nL:ALIH 1JLFAKIIV1LIN l <br /> ' SERVICE REQUEST <br /> T e of Business or Property FACILITY ID# SERVICE REQUEST# <br /> bOQ3 lv o <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME \, \ <br /> O Fb�& L1. C <br /> SITE ADDRESS Ws— 1 \ O �1� ( � \ <br /> Street Number Direction l" Y`�U Street Name Ci / Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> X09) 333 , X03 Ix <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR rvr <br /> CHECK if BILLING ADDRESS 4&J <br /> BUSINESS NAME P NE# EXT. <br /> 1c- ( 6 '-4 - <br /> HOME or MAILING ADDRESS,- FAX# <br /> IS3S (20 ) tlbl - 6 3H2 <br /> CITY �O C 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,Standard , STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: (��Q DATE: 3 v <br /> PROPERTY/BUSINESS OWNER PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT I, <br /> If APPLICANT not th BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO REL E 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 /> RAYINAENT <br /> COMMENTS: RECEIVED <br /> MAR 1 0 2003 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPROVED BY; rT� EMPLOYEE#: _ DATE: 3 ®/b 3 <br /> ASSIGNED TO: EMPLOYEE IV DATE: 3 r4 <br /> / � a3 <br /> Date Service Completed (if already completed): SERVICE CODE: - — °��� PIE: <br /> Fee Amount: 2-6 747° I <br /> Amount Paid Payment Date _3 <br /> Payment Type Invoice# Check# �1 Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />