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SAN JOAQ- Q COUNTY ENVIRONMENTAL HEAT 'll DEPARTMENT <br /> SERVICE REQUEST "' F <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ OPERA <br /> CHECK If BILLING ADDRESS E] <br /> FACILITY NAME A&j/O <br /> SITE ADDRESS �. <br /> 7i <br /> Street Number Direction S�eerNa-me Ci[ ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS E] <br /> BUSINESS NAME T� PHONE EXT. <br /> HOME Or MAILING ADDRESS FAX If 7P <br /> CITY L _ STATE �L P <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 HEALTFI DEPARTMENT hourly Charges associated with this projector <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 Cortes,Standards, STATE and ELLIE RAL Vis. <br /> APPLICANT'S SIGNATURE: ¢-/� /� DATE- , .. — <br /> EE e <br /> PROPERTY/B LISW ESS OWN ER EI OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <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 environmentaUsite 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: S(.._- _ PAYMENT <br /> COMMENTS: RECEIVED <br /> JUN 3 0 2003 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMFNITAL HEALTH DIVISION <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: C1 h17 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E:c <br /> Fee Amount y_" — Amount Paid Payment Date 0 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />