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SAN JOAQUCOUNTY ENVIRONMENTAL HEAL DEPARTMENT <br /> SERVICE REQUEST <br /> T f of Busin s or Property FACILITY ID# SERVICE REQUEST# <br /> O NER/ OPERATOR <br /> CHECK if BILLING ADDRESS <br /> ILITY NAMr� <br /> e <br /> SITE`ADD ESS <br /> '! Street Number Direction Street Name bit / i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> �i Street Number Street Name <br /> CITY � -"STATE ZIP , <br /> P! <br /> PIiONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT --71 LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOFq6tylUj•� <br /> U CHECK If BILLING ADDRESS <br /> BUSINESS NAME(I PH EXT. <br /> &Aar& dfo- <br /> HOME Or MAILING ADDRESS F <br /> CITY / f �- 7 <br /> ZIP , <br /> BILLING KNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH 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 TATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: JLI'lk� DATE: 9 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGFR ❑ OTHER AUTIIORIZFD ACENr <<20�v <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTI-IORIZATION 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 HEALTii 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: 4'� <br /> COMMENTS: <br /> P ?2 70 <br /> SOP°'3tN`'0 v�CEs <br /> SPN l\G NEP�jNF.P RN NN,S10N <br /> PU NMFNjp <br /> �I1RG <br /> APPROVED BY: �I `� , � EMPLOYEE#: 2- DATE: 0 <br /> ASSIGNED TO: ��n /l, EMPLOYEE#: gJ�j/;L DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 9�t� P I <br /> Fee Amount: c;-:2714?,ov I <br /> Amount Paid is2,1 C-r Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> ` EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />