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SAN JOAQUIN CTY 'ENVIRONMENTAL HEAL'1'l-► 'AR'1'MEN'►' <br />SERVICE REQUEST <br />ype of Business or Property <br />6<c> "6-, P <br />�� <br />1[ <br />FACILITY ID # <br />L-6 6 � tf 5-73 <br />RECEIVED <br />SERVICE REQUEST # <br />WNER /OPERATORCHECK <br />[FACILITY <br />I. <br />MAR 12 2003 <br />if BILLING ADDRESS Er <br />NAME1 _ <br />EITE <br />FAX # <br />ADDRESS <br />2 r Street Number <br />�� CL71'l <br />DlrecOon <br />APPROVED BY: <br />Street Name <br />-6 <br />q -6,1,, - <br />CII <br />STATE G1 <br />STATEG`j <br />ZI Codc <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />EMPLOYEE #: ?3 <br />Street Name <br />CITY <br />SERVICE CODE:Gt <br />PIE: 23� <br />STATE zip <br />Fee Amount:Amount <br />PHONE #t <br />EXT. <br />APN # <br />LAND USE APPLICATION ft <br />Payment Type <br />PHONE #2 <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />® CONTRACTOR / SERVICE REQUESTOR <br />REOUESTOR <br />i <br />CHECK If BILLING ADDRESS ❑ <br />BUSINESS NAME <br />RECEIVED <br />PHONE # <br />EXT. <br />I. <br />MAR 12 2003 <br />- <br />H E or MAILING ADDRESS <br />FAX # <br />�[�?"'" <br />APPROVED BY: <br />1��) <br />-6 <br />q -6,1,, - <br />DATE: . <br />STATE G1 <br />STATEG`j <br />zip C?�5-2 O <br />n <br />EMPLOYEE #: ?3 <br />DATE: <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 I-IEALTI-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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Stand rds, STATE and. EDERAL laws. <br />APPLICANT SSIGNATUI� A-'� DnTt:: 3 " /2,^03' <br />PROPERTY / BUSINESS OWNER ❑ OPHRATOR / MANAG& ❑ OTIIGR AUTIIORIZLD AGENT ❑ <br />IfAPPUCANT is not the BILUNG 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 LNVIRONMENTAL 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: <br />i <br />COMMENTS: <br />RECEIVED <br />L <br />MAR 12 2003 <br />MAR 12 2003 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENPUBLIC T HEALTH <br />HEALTH VICES <br />ENVIRONMENTAL HEALTHDIVSION <br />�[�?"'" <br />APPROVED BY: <br />EMPLOYEE I <br />DATE: . <br />ASSIGNED TO: <br />n <br />EMPLOYEE #: ?3 <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE:Gt <br />PIE: 23� <br />Fee Amount:Amount <br />Paid deP - <br />Payment Date J <br />Payment Type <br />Invoice #Check <br />#� <br />Rec,eived By: <br />®EHD 40-01-025 SERVICE REQUEST FORM <br />REVISED 6-5-02 <br />