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SAN JUIN COUNTY ENvmoNMENTAL H*TH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY Ip# SERVICE REQUE,STTy# <br /> 06 <br /> 0 <br /> W ER OPERATOR <br /> CHECK if BILUNG Z.R <br /> Jf <br /> FAc><rrY NAME <br /> T� <br /> SPIE ADDRESS c�Pt,-TT—� �N \ <br /> Street Number r +� Zl ode <br /> HOME or MAILING ADDRESS (if Different from Site Address <br /> Street Number a <br /> CITY STATE zip <br /> PHONE#t ExT. APN 0 I LAND USE APPLICATION# <br /> ( <br /> PHoNE#2 Ems. BOS DISTRICT LOCAAON CODE <br /> CONTRACTOR f S VICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS D <br /> BUSINESS NAM PHONE ExT. <br /> Ho mE or MA UNG ADDRESSr FAx# !C/ <br /> CITY �C' c STAT!j +,- ZIP <br /> ----J1�� !! <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 ' entified on this form <br /> I also certify that I have prepared this ap ti and that the wor lie performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards d FED la <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY 1 BUSINESS OWNER OPERATOR/MANAGER ❑ OTTmmAUTHOR=D AGENT C] <br /> If APPLICANT is not the BILLINGPAR, proof of authorization to sign Is required Title <br /> AUTHORIZATION TO RELEASE INFORMATIQN: 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: �%1 � � PAYMENT <br /> COMMENTS: <br /> N O V 2 1 Z00$ <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: . EMPLOYEE#: I DATE: 117 <br /> �- - <br /> Date Service Completed (if already completed): SERYICE CODE; PIE: <br /> Fee Amount: 1 Amount Pald 3/� _ Paytne t Date <br /> Payment Type Invoice# Check# (,\rte', Received By. <br /> r <br /> EHD 48-02-025 = <br /> REVISED 11/17/2003 �' <br />