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SAN JOAQUIN `'UNTYENVIRONIVIENTALHEALTPt ' EPARFINIENT <br /> SERVICE REQUEST <br /> Type of Business or Property _ FACILITY ID# SERVICE REQUEST# <br /> 2eT'41c F-0 OD CG 11 1 0 <br /> OWNER/OPERATOR <br /> 'F 6 N A / /� N �e 0 `N P Nom' CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME (� <br /> SITE ADDRESS P �-F0 C 1.,--—70 Q S 21 / <br /> -� I Street Number Direction C J Ft C Street Name Ci Zin Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (;Lel ) 9 '1G - 2r6S <br /> PHONE#2 2 E,• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORCHECK if BILLING ADDRESS❑ <br /> V 1 <br /> BUSINESS NAME PHONE# EXT, <br /> t>� eTiT A G c C o �0 <br /> HOME or MAILING ADDRESS FAX# <br /> oo ((. 5-o) 0 <br /> CITY PA-Z STATE C A ZIP Gf Y 3 I <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 busi s as identified on this form. <br /> I also certify that I have prepared tl s ap lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stand -ds, TAT- and FEDERAL 14WS. <br /> APPLICANT'S SIGNATURE: w DAT�Ey <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT LJ t S /� �J A N✓� eIL <br /> If 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 environmentaUsite 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: ' L <br /> COMMENTS: f <br /> RECEIVE . <br /> JUNI 2 7 <br /> SAN JOAQUIN .' <br /> PUBLIC HEALTH <br /> APPROVED BY: ( , ) � EMPLOYEE#: �� DATE: <br /> ASSIGNED TO: EMPLOYEE#: �I+ DATE: <br /> Date Service CompYet (if already completed): -� .3 SERVICE CODE: P I E: 1 L L <br /> Fee Amount: L Amount Paid Fye Payment Date <br /> Payment Type Invoice# Check# Received By: ; <br /> EHD 48-01-025 SERVICE REQUE%FORM <br /> REVISED 6-5.02 <br />