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SAN JOAQUINIW"" UNTY ENVIRONMENTAL HEALTL�EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> c)-� fA 3�W (2 �37 5re,196 V/ -,�5 7 5 <br /> OWNER PERATOtZ <br /> CHECK If BILLING ADDRESS <br /> - <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Numberbi�'ection Street Name Cit 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 /> PHONE#2 EXT. ffDISTRICT LOCATION CODE <br /> 7] <br /> CONTRACTOR / SERVICE RE, QUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> 5BUSINESS NAM I PHONE# EXT. <br /> -rv�% " �� <br /> HOME Or MAILING APDRESS FAX# <br /> CITY _al, STAN zip S-20 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTi-t DEPARTMENThourly 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, STATE and FEDERAL laws. J <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/QUSINFSS OWN. 'F.RATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> I APPLICANT is not the BILLING PIR7Y_proof of authorization to sign is required Tide <br /> AUTI-iORIZAT10N 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. I <br /> TYPE OF SERVICE REQUESTED: Lk Sr( <br /> COMMENTS: <br /> SAN JOAQUIN COUNIV <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: V L EMPLOYEE#: J� DATE: <br /> ASSIGNED TO: EMPLOYEE#: �i� DATE: d t� <br /> J O <br /> Date Service Completed (if already completed): SERVICE CODE: / P/Ea3,0 <br /> —7 <br /> Fee Amount: J - 00 Amount Paid o;_ ��-1 Payment.Date <br /> Payment Type Invoice# Check# 5-rt tf6 Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />