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,JAIN JOAt1UIIN k-OUIN IV LiN V1KV:N1V1E1N IAL n ALIR UL+'YAK11V1L1N I <br />It 0 SERVICE REQUEST • <br />,fypy �f Business or roperty <br />1, <br />KI <br />FACILITY ID # <br />D 0o <br />SERVICE REQUEST # <br />i2 O(Y35 9��j <br />OWN / OPERATO <br />REC \/E <br />EXT. <br />HOME or MA[LdNGADDRESS <br />c.cU9i <br />FAX# <br />CHECK if BILLING ADDRESS ❑ <br />FACILITY NAME <br />SAN JOAQUIN COUNTY <br />DES <br />CITY1 /J ® STATE <br />zip �%.v <br />SITE ADDRESS <br />Street Number <br />Dlirte_cJtion <br />EMPLOYEE #: <br />Sti <br />DATE: <br />lit/j <br />0� <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Street Number <br />Date Service Completed (if already completed): <br />Street Name <br />CITY <br />Fee Amount: �2-G-72a2 <br />Amount Paid ,� t'�'7 ,— <br />STATE ZIP <br />PHONE #1 EXT. <br />> Ll 7y - 9NY <br />Invoice # <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTO <br />rAhh /,I, A&Aj <br />CHECK if BILLING ADDRESS <br />BUSINESS NAM t'PHONE# <br />01lik, ic�t4z�� <br />REC \/E <br />EXT. <br />HOME or MA[LdNGADDRESS <br />c.cU9i <br />FAX# <br />`.;�. <br />SAN JOAQUIN COUNTY <br />DES <br />CITY1 /J ® STATE <br />zip �%.v <br />BILLING A&NOWLEDGEMENT: 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, STAT nd FEDERAL laws. <br />APPLICANT'S SIGNATURE: ` /2 DATE: —/ 7 O3 <br />PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT D/ <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. 2709 - <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />REC \/E <br />MAR 17 2003 <br />SAN JOAQUIN COUNTY <br />DES <br />FWAONMENTAL HEALTH IVISION <br />APPROVED BY: <br />EMPLOYEE #: <br />OpI <br />CCN <br />DATE: <br />ASSIGNED TO: ; <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: l <br />P f E: ;3(D <br />Fee Amount: �2-G-72a2 <br />Amount Paid ,� t'�'7 ,— <br />Payment Date 3 / 07-5 <br />Payment Type <br />Invoice # <br />Check # <br />Received By: y Q <br />EHD 48-01-025 SERVICE REQUEST FORM <br />REVISED 6-5-02 <br />