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a , <br /> I <br /> SAN JOAQU COUNTY ENVIRONMENTAL HEAL; DEPARTMENT <br /> _ SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> i <br /> OWNER I OPf:RA OR <br /> 0. V. n B o�h r t{,I j CHECK If BILLING ADDRES <br /> FACILITY NAME <br /> SITE ADDRESS Q V (� Air, <br /> r,�O n� 161� �J1(A 11 fe� <br /> Slreot Number pireclion �'[ Slree!Name I 1 ! Cit ZipCode <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 AP LICATION# <br /> aO k4 1p- C)I - CT <br /> PHONE#2 Ext• BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS D <br /> F BUSINESs NAME PHONE# ExT. <br /> S U C, f�C G CO <br /> HOME or MAIL114G ADDRESS FAX# <br /> CITY STATE 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 HEALTi1 DEPARTMENT hourly charges associated with this project or <br /> activity will bc: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 and FEDERAL laws. <br /> Al'PLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I MANAGER ❑ OTHER AUTIIOR[ZED AGENT❑ <br /> If AIII'LICANT iS not Me BILLING PARTY,proof of authorization to sign is required Tide <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 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 /> COMMENTS: �! vl Q J nV�`V U VV- &fL s }42 {f- <br /> ey-- <br /> $-et <br /> SR003 -L-70G <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type -TI nvoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6.5.02 <br />