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SAN JOAQUIP.-OUNTY ENVIRONMENTAL HEALTH AARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ��QL!/V1T fEJ2d(G6� 3- (o►✓ ` f ' ' - ! <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> �avYNar.� Pflicc�Pf' <br /> FACILITY NAME <br /> SITE ADDRESS ' q�3 741'Street Number irection C �C / Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 7C Vo�� <br /> Street NumberCITY <br /> Street Name <br /> !;Aek p-r-1 STATE ZIP b <br /> PHONE#'l EXT. APN# LAND USE APPLICATION# <br /> (06 ) 5-579 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> //Ir!„[—�rr CHECK If BILLING ADDRESS <br /> BUSINESS NAME C/� /v(3 PHONE ExT. <br /> 70'20 <br /> HOME or MAILING ADDRESS FA'X# <br /> 2 514- %w - (3ordAvK U4*9 (74) McO 6 Q'AA' <br /> CITY R ,/n /►M 11 STATE A ZIP <br /> BILLIN,7GVA/C �}CKKNOW,fLEDGEMENT: 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 <br /> or 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 an ED L laws. 1 / <br /> APPLICANT'S SIGNATURE: DATE: f�F�—0� <br /> PROPERTY/BUSINESS OWNER❑ OPERATO /MANAGER ❑ OTHER AUTHORIZED AGENT <br /> I <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. A ! N <br /> TYPE OF SERVICE REQUESTED: F 17— <br /> COMMENTS: ICOMMENTS: rL�O <br /> JAN Go�N� <br /> SP�N� <br /> APPROVED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: (gyp EMPLOYEE#'r ° DATE: •� <br /> Date Service Completed (if already completed): SERVICE CODE: ' G P/E:' ! <br /> Fee Amount: , -1 Amount Paid Pa merit Date d <br /> Payment Type Ll' Invoice# Check# Received By: �t <br /> EHD 48-01-025 SERVICE REQUEST FORM �T <br /> REVISED 6-5-02 <br />