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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> / TA� k /i-S 7—� �Z- <br /> FACCHECK If BILLING ADDRESS❑ <br /> FACILITY NAME (/C <br /> E n/ I-A NP S P o N/ u PPS <br /> SITE ADDRESS S /1� rO Al 12-66 �R�C`/ ?5-3 740 <br /> Street Number Direction /'` J Street Name Ci 1 Zip 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 LISEWPPWCATION# <br /> ( ) -476 -aw .7-3 9 -060- 0* — ;L- <br /> PHONE#2 EXT. BOS DISTRI OCATION CODE <br /> L <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> GCs A/g CHECK if BILLING ADDRESS Ely <br /> BUSINESS NAME /v v PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> E 42 . UOSC 3-7-94 ( ) <br /> CITY u nL0 L 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 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 appl' ion and tha work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, T and FED S. <br /> APPLICANT'S SIGNATURE: DAT <br /> �Ey <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ O ER AUTHORIZED AGENT 117 <br /> If APDL/CANT is not the Blt_LING PARTY.proof of autho Ration 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 HEALTEI 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: 50/L Ju i TA 131c r STS.!j> AD DD,�n/D u�-t ,�E✓/ �(ME <br /> COMMENTS: <br /> I L6i-9s �✓� �� 1'� 203 <br /> �� N �c <br /> x;4 � �+ Dov <br /> ��P oNME��SNS <br /> Gd M ✓. Vii' ENVA&L�NpEPPRSM <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> 111117 �? <br /> ASSIGNED TO: EMPLOYEE#: % /�� DATE: <br /> c <br /> Date Service Completed (if already completed): SERVICE CODE: Z Z PIE: <br /> Fee Amount: 11 / } Amount Paid Payment Date <br /> Payment Type tG Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />