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:iAN J OAQUIN N'I'X I:NVIRONMLNTAL HEAL'1'i , I'AR'I'MLN'.1 <br />SERVICE RE QUEST <br />Type of Business or Property <br />COMMENTS: <br />APPROVED BY: <br />FACILITY ID # <br />BUSINF,SS NA E <br />12Ed - tri <br />SERVICE REQUEST # <br />OWNS PERAT <br />HOME or MAILING ADDRESS S . <br />' / ®� <br />Date Service Completed (if already completed); <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />STATE,,.A zip t- <br />;Amount Paid . <br />Payment Date, <br />SITE ADDRESS <br />/ Street Number <br />� ` <br />DIr Jlon <br />Check # <br />/ t tr et Name <br />Ctt <br />21 Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 . <br />( ) <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />REQUESTOR <br />COMMENTS: <br />APPROVED BY: <br />CHECK If BILLING ADDRESS <br />BUSINF,SS NA E <br />12Ed - tri <br />r—" <br />��`• <br />PHONE# EXT. <br />zoq 64-83'33 <br />HOME or MAILING ADDRESS S . <br />' / ®� <br />Date Service Completed (if already completed); <br />FAX # <br />( ZO ) 114• -GV W <br />CITY r <br />STATE,,.A zip t- <br />1311,LiNG ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of sank,. <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 any 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, Slandards,, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: Q � . ITATV- <br />PROI-mcry / IIUSINEss OWNER OPERATOR/ MrNAGER ❑ OTHER AUTIIORizzD AGENT ❑ <br />If /tPPUCANT is not the BlGUNG 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. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />APPROVED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed); <br />SERVICE CODE: <br />PIE: <br />Fee Amount: <br />;Amount Paid . <br />Payment Date, <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 4"1-025 SERVICE REQUEST FORM <br />REVISED 6.5-02 <br />