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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUESTT# <br /> OWNER/QRZ ATOR CHECK If BILLING ADDRESS <br /> J 2f i <br /> FAcLm NAME / �I <br /> SITE ADDRESS ( 9Meat Numlror Diraelbn �,S/ �N C�/�C. ��/ Zip Code/ G.� C <br /> HOME 0 AILING ADDRESS (if Different from Site Address) <br /> ^ <br /> t/ �2 J Slreet Numbw Street Nama <br /> Cm' / I O STATE ZIP �� <br /> PHOKE#I / En APN# LAND USE APPLICATION# <br /> (2,o q) 33 <br /> PHDNE92 fir. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SEF VICE REQUESTOR <br /> REQUESTOR CHECK if BILLING AODRESSE] <br /> -zf2Z ���� oil iac. <br /> PHONE# ' <br /> BUSINESS NAME Q�C �1/AC <br /> HOME or MAIUNG ADDRESS I, /eZ <br /> CITY / / STATE n ZIP 5 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned prop(: -y or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTA'. iEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on thi: )rm. <br /> I also certify that I have prepared this application 3nd that the wor :o be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE'yfXF2UkRA0 aw <br /> 10-el- <br /> APPLICANT'S SIGNATURE: DATE: <br /> L 7 <br /> PROPERTY!BUSINESS OWNER[;] PE TOR/MANAGE ❑ OTHE L7HORIZED ACSrPf��QtJ��/�C <br /> If APPLICANT t the Bl IV( <br /> V PAerr proof of out orizadon to sign is required rice <br /> AUTHORIZATION TO RELEASE I FORMATION: When ,-'plicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and a. results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL":DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. G, <br /> ENT <br /> TYPE OF SERVICE REQUESTED: U -/1 f 7 <br /> / RECEI <br /> LU <br /> COMYEMS: piPR 2 8 2004 <br /> SAN JOAQUIN COUNTY <br /> HEALTH DEPAH MENT <br /> APPROVED 6 . EMPLOYEE#: �! DATE: <br /> ASSIGNED TO: Cr EMPLOYEE#: P DATE: 1 V <br /> Date Service Completed (if alre dy ompleted): SERVICE CODE: I - P/E: <br /> Fee Amount: -. !� �� Amount Paid f>L41g,'. S—D Payment Date ry y n y <br /> Payment Type V," Invoice# Check# �D(o Received By: <br /> EHD 49-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />