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SAN ,J OAQUIN IDUNTY ENVIRONMEN'T'AL HLALT0k PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Q- +60 <br />FACILITY ID # j ; <br />SERVICE REQUEST # <br />rvc, r <br />MAR 1 92003 <br />UV7/40(DO I - <br />0013133 <br />U C' V- <br />HAOUNTy <br />SERVICES <br />NATSI <br />FAX # <br />CITY � <br />OWNER / OPERATOR <br />STATE Ccl ZIP 9S2 6, <br />+�� \ <br />CHECK if BILLING ADDRESS <br />t \tom 1 <br />FACILITY NAME <br />PIE: 23�� <br />Fee Amount: '� <br />Amount PaidPayment <br />SITE ADDRESS <br />Date 3 13 <br />i <br />1 <br />S -m e- - <br />c c c <br />C� S3 7� <br />Street Number <br />Directlon <br />Street Name <br />CIA <br />ZI Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Street NumberT <br />Street Name <br />CITY <br />STATE zip <br />PHONE #1 EXT. <br />APN H <br />LAND USE APPLICATION N <br />Zvi) `b3 — l<6 10 <br />PHONE #2 _ EXT. <br />ci <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Z <br />_v\ <br />Q- +60 <br />CHECK If BILLING ADORES <br />BUSINESS NAME_ <br />► e <br />rvc, r <br />MAR 1 92003 <br />PHONE# EXT. <br />vG 461 <br />HOME Or MAILING ADDRESS <br />HAOUNTy <br />SERVICES <br />NATSI <br />FAX # <br />CITY � <br />(� <br />3 <br />STATE Ccl ZIP 9S2 6, <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 1-IEALTFI 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, Stand -ds, STATE and FEDERAL laws. <br />1 ' <br />APPLICANT'S SIGNATURE: �Jl�-�-� DATE: <br />PROPERTY / BUSINESS OWNER 1 OPERATOR / MANAGER ❑ OTHER AUTHORizrD AGENT W�- <br />If APPLICANT s not the BILLING PARTY, proof of authorization to sigh is required Title <br />A THORIZATI N TO R - SE 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 />COMMENTS: <br />REFI VEo <br />MAR 1 92003 <br />9AN JpA0U1 <br />IC <br />ftqONMET <br />HAOUNTy <br />SERVICES <br />NATSI <br />APPROVED BY: <br />EMPLOYEE #:DATE: <br />�Z� <br />(� <br />3 <br />ASSIGNED TO: <br />EMPLOYEE #: '7 J <br />DATE: <br />Date Service Completed (it already completed): <br />SERVICE CODE. 61 <br />PIE: 23�� <br />Fee Amount: '� <br />Amount PaidPayment <br />Date 3 13 <br />Payment Type O <br />Invoice # <br />Check # �� <br />Received By: <br />EHD 48-01-025 SERVICE REQUEST FORM <br />REVISED 6-5.02 <br />