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SAN JOAQI COUNTY ENVIRONMENTAL HEAL*DEPARTMENT <br /> SERVICE REQUEST <br /> Typpeeusiness or P erty FACILITY ID# SERVICE REQUEST# <br /> OWNER4 OPERgLT•OR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SIT ADDRESS f C. <br /> '� <br /> Sired Number Direction 1. Street Name Cit /vLi C deo <br /> HOM or MAILING ADD SS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> M <br /> #1 EXT. APN# LAND USE APPLICATION# <br /> ) -v95� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE I2EQUESTOR <br /> REQUESTOX11 ' <br /> /'n CHECK if BILLING ADDRESS <br /> V l ' 3/E.T. <br /> BUSINESS NAME � e I Ai <br /> PHON <br /> HOME Or MAILING ADDRESS L�a <br /> a// v �/ . FAX# 9) <br /> CITY /)jI t l(�/� T 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 HEALTI I 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 plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Cortes,Standars, TATE and FrDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: �U <br /> OP <br /> PROPFRTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTIf APPLICANT 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 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: /6T_ <br /> Ste_ <br /> COMMENTS: RECEIVEC <br /> JUN 4 2003 <br /> SAN JOAQUIN CoLiN I- <br /> n n PUBLIC HEALTH SERVICE` <br /> ENVIRONMENTAL HEALTH <br /> APPROVED BY: EMPLOYEE#: 5LIZ DATE: <br /> ASSIGNED TO: • �� Gam, EMPLOYEE#: 3 DATE: <br /> Date Service Completed (if acre dy completed): SERVICE CODE: <br /> Fee Amount: Amount Paid �®t� Payment Date <br /> Payment Type Invoice# Check# 2� 7 Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />