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SAN JOAQUIT -OUNTY ENVIRONMENTAL HE,ALT' `EPARTMENT <br /> u SERVICE REQUEST ..i <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1.N ILI cg x-003)5 1 <br /> OWNER I OPERATOR ��/,( <br /> G/ V /7© ele -O � / CHECK If BILLING ADDRESS 4a J <br /> FACILITY NAME r`J / <br /> crC/ 6Ic Tve /C' TdN <br /> SITE ADDRESS /ale e--o ? fie <br /> �� W F <br /> o 9%dc�eToM <br /> Street Number Direction - oo,e�(J Street Nam 0 <br /> city 9Zip dG2 <br /> HOME or MAILING ADDRESS (If Differentfrom Site Address) a,9- <br /> Street Number �'U�T` rSYlr/eet Name I`~"� <br /> CITY // STATE ZIP <br /> y,Y e Qd <br /> PHONE#1 Ear' APN# LAND USE APPLICATI # <br /> (ao 93 7 - rg, yd <br /> PHONE#2 EaT• BIDS DISTRICT LOCATION CODE <br /> ( 1 i <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EaT. <br /> G ��FON Ne �g 60 ' <br /> HOME Or MAILING ADDRESS FAX#' <br /> S' &aiIL/ TY4 (9 Jx I - r- 36 2 <br /> CITY e ocp'rn 6 N'T(J STATE etv- 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 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. 2 <br /> APPLICANT'S SIGNATURE:<-- T DATE: <br /> PROPERTY/B USIN ESS,OWN Ell El OPERATOR/MANAGER ❑ OTHEri AOTr1ORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required F Title Ll <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 ENVIRONMEN-rAL HEALTH DEPARTMENT as soon as it is available and at the sante time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> C21 N� <br /> O ,PN,O NEP NEP NOENS\N <br /> POgEMENSP� <br /> ��NON <br /> APPROVED BY: eqEMPLOYEE M ('/[ill DATE: <br /> ASSIGNEDTO: L ?' - EMPLOYEE#; u o0�q DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: 13f 2-301 AII <br /> Fee Amount: j'j_QL Amount Paid 3 Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> S <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />