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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST db <br /> Type of B iness or roperty FACILITY ID# SERVICE REQUEST# <br /> Via (' Sf � <br /> OWNERI OPERATOR <br /> Q CHECK If BILLING ADDRESS <br /> FACILITY NAME SawIj <br /> SITE ADDRESS L <br /> Street Number Direction St,. Name r a. Hv <br /> L ZI Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY O STATE ZIP <br /> PHONE#1 EXT.gcpf 7i;N# LAND USE APPLICATION# <br /> PHONE#2 ExT• SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEIS a PHONET' <br /> /- (0 3I/ <br /> HOME or MAILING ADDRESS FAX# <br /> e)) 1�6If- 63q-2 <br /> CITY STATE ZIP 9 -- <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STJ and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: /f _ �(�J�J DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT4l <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 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: lhJ% l Lon &Y,MENT <br /> COMMENTS: RE <br /> OCT I % ZV <br /> SA14 NVI pONMFWAL <br /> HEALTH DEPAt1TMEM <br /> ACCEPTED BY: EMPLOYEE#: ©- (D <br /> > DATE: <br /> ASSIGNEDTO: EMPLOYEE#: 2la� DATE: InlL D <br /> Date Service Completed (if already completed): SERVICE CODE: 1 E. 2 30 <br /> Fee Amount: a It, Amount Paid �_q {, Payment Date 1 <br /> Payment Type f Invoice# Check# �3� Received By: <br /> EHD 48-02-025 <br /> REVISED II/17/2003 <br /> f <br />