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W <br /> SAN JOAQUIN 'I'Y ENVIRONMENTAL I-1EAL'1'H41I'AR'I'MEN'I' <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK it BILLING ADDRESS <br /> FACILITY NAME S <br /> I 1y1�2,1�e'y� <br /> SITE ADDRESS P4A <br /> ��-3Slreel Number Direction `-�e,Name ZiCode <br /> HOME or MAILING ADDRESS (1f Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#I EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEqIDR <br /> � r .n ^G �� n <br /> :��kes CHECK It BILLING ADDRESS <br /> BUSIN SS AME V —' ! '` r / PHON N EXT' <br /> L ��2 w�rv. J L r?5 3 _U�s� <br /> HOM r MAILING ADD ESS FAX# <br /> CI STAT /i ZIP 7 <br /> 1311,11ANG 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 pplicati and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stand rds TATE a FEDERAL laws. <br /> 1 <br /> APPLICANT'S SIGNATUR fGt�-��; DATL: <br /> Pit01'L1tTY/BUSINI4SS OWNER❑ PERATOR/MANAGER ❑ OTIIEIt AUTIIORIZED AGENT❑ <br /> If Ai'PLICANT 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> PAY MEN T <br /> RECEIVED <br /> JAN 2 7 2003 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> C•t <br /> APPROVED BY: EMPLOYEE#: 1 DATE: <br /> ASSIGNED TO: EMPLOYEE#: ( DATE: <br /> Date Service Completed (1t already completed): SERVICE CODE:1 PIE: /� ( <br /> Fee Amount- q ' 7 9? Amount Paid '2 Payment Date / r�/ P3 <br /> Payment Type Invoice# Check# Received By: �. <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5.02 <br />