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' JAiN JOAQUIN II:OUNTY ENVIKONMEN'fAL 14EAL'TH DEPAKTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SVICE REQUEST# <br /> ` � d00_3736 16�0;30 -,L/ <br /> OWNER/OPE OR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILOr ct�t / Cl I <br /> SITE DDRESS6 L �,J 4 W r � 1 SIN <br /> r C. C� <br /> DL- Street Number Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If 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 /> i CONTRACTOR/ SERVICE REQUESTOR <br /> REQ UESTOR <br /> CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# i ExT. <br /> 3 �� - 12 <br /> HOME or MAILING ADDRESS F 2# l 9 <br /> Y ( ) .36 <br /> CITY * STATE ZIP <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 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTI,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: OsT <br /> COMMENTS: <br /> N� <br /> APPROVED BY: EMPLOYEE <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: p�'✓ EMPLOYEE#: DATE: . <br /> Date Service Completed (if already completed): SERVICE CODE: �(� 1+1E: 3b <br /> Fee Amount: l Amount Paid �' Payment Date <br /> Payment Type Invoice# Check# � Received By: <br /> EHD 48-01-025 SERVICE REQUESTrf ORM <br /> REVISED 6-5-02 <br /> 47 <br />