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SAN JOAQZ COUNTY ENVIRONMENTAL HEA1 <br /> 9DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Prop y FACILITY ID# SERVICE REQUEST# <br /> An 'd FAo)vo F 5' Qo101 2+991 <br /> OWNER I O ERATOR it <br /> !1! j CHECK if BILLING ADDRESS <br /> FACILITY NAM <br /> SITE ADO16"'uN <br /> ���j/� /"/']//�//�/mber Direction [/&��Street Name / A L � <br /> HOME Or MAILING AD DR If D" er t from Site Address) <br /> Street Number Street Name <br /> CITY � <br /> STATE ZIP <br /> PHONE# APN# LAND USE APPLICATION# <br /> PH E#2 �ExT. BOS DISTRICT LOCATION CODE <br /> 7 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORUUV--,'L r�///(Jt� CHECK if BILLING ADDRESS <br /> LiBUSINESS NAME �L?/ P Exr. <br /> HOME Or MAILING DDRES FM V" � / -&,3 q2- <br /> I aa��,'I,[/ <br /> CITY STATE IP <br /> BILLING ACKNOW EDGEMENT: 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 a q <br /> FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 4- W-Zo <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT CIL' <br /> /f APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 andlor 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: J I r <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVED <br /> AUG 12 2003 <br /> JOAQUIN COUNTY <br /> APPROVED BY: EMPLOYEE#: ;?a,l HF:.AI?H <br /> ASSIGNED TO: EMPLOYEE#: DATE: r _ 0 <br /> Date Service Completed (if already completed): SERVICE CODE: 1 PIE: <br /> Fee Amount: , Amount Paid Payment Date 0 3 <br /> Payment Type Invoice# Check# j Received By: <br /> EHD 48-01-025 SERVICE REQUEST FOPM <br /> REVISED 6-5-02 <br />