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SAN.JOAQUIUNTY ENVIRONMENTAL HEALII EPARTMEN`I' <br />SERVICE REOUEST <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />3 ` <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME 1 ,1 <br />L <br />PHONE # <br />EXT, <br />a yb <br />_ <br />33 <br />HOME Or MAILING ADDRESS <br />gAN SOACII jN COUNTY <br />PURI-tiG HEALTH SER�4CE }�,ti,,N <br />FAX 11 <br />j <br />CITY <br />c <br />STATE cl� zip <br />`• <br />I C <br />I .i <br />BILL[ G 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. n II <br />)ZPROAPPLICANT'S SIGNATURE: WO LWIDATA;: .L q _ c)'2– <br />PROPERTY <br />PERTY / BUSINESS OWNER ❑OPERATOR I MANAGER ElOTIIGR AUTIIORIZED AGENT' S F <br />IfApniCANT is no Ie &LUNG 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: c} J <br />O <br />gYME�T <br />COMMENTS: <br />DEC 62402 <br />gAN SOACII jN COUNTY <br />PURI-tiG HEALTH SER�4CE }�,ti,,N <br />ENV4ROI�MFN�I iFk}T <br />APPROVED BY: �%"t/f / <br />EMPLOYEE #: f <br />DATE: J� 2— �. <br />ASSIGNED TO: 1° <br />EMPLOYEE#: 03 0'!� <br />DATE: Z/, --e <br />Date Service Completed (if al dy vmpleted): <br />SERVICE CODE:P <br />IqQ <br />J E: <br />�--3 0 <br />C� <br />Fee Amount: a� <br />Amount Paid <br />t��� <br />Payment Date 171) � <br />Payment Type <br />Invoice # <br />Check # �(��� <br />Received By: Z1(-- <br />EEO J SERVICE REQUEST FORM <br />-025 <br />8. <br />REVISEDSED 6-5--00 2 <br />