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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> ' SERVICE REQUEST <br /> Type of Busi s or Prope FACILITY ID# SERVICE REQUEST# <br /> C 7"'-3 s�©� <br /> OWNER/OP TOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS C- i'I t��/ a l UC4a fil 'I <br /> Street Number i ion (/ Street Name C' Zi 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 /> a 9) _ 5 23 2 - t,7o-c�3 <br /> PHONE#2 ExT. BOS DISTRICT LOC <br /> jrlsl CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR a26U <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHON EXT. <br /> PO4 4Aa <br /> l- 331 <br /> HOME or MAILING ADD SS FAX# <br /> CITY STATE ZIP L <br /> BILLING ACKNOWLED EMENT: 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 accoceth all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA d FEDERAL law <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 enviromnental/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. p <br /> TYPE OF SERVICE REQUESTED: 7-X2-U 17— ECE� NT <br /> COMMENTS: JUN 2 O p 200 <br /> 7 <br /> SAN j0AQU/ <br /> H�ALTE1Vy p pA�MYN7Y <br /> NT <br /> ACCEPTED BY: 0L L vE /CJ EMPLOYEE#: ?)Z� DATE: 6 7 <br /> ASSIGNED TO: EMPLOYEE#: C, 5&� ATE: 12-f-107 <br /> Date Service Completed (if already com eted): SERVICE CODE: Q PIE:Z3 Ge <br /> Fee Amount. a tS Amount Paid Payment Date b �-7 <br /> Payment Type Invoice# Check# r\- Received By: <br /> EHD 48-02-025 SR OR'I ;( olden aoii) <br /> REVISED 11/17/2003 <br />