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SAN JOAQUI) OUNTY ENVIRONMENTAL HEALT EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID#C�rSERVICE REQUEST# <br /> A F -7 <br /> OWNER/ OPERATOR <br /> CHECK If BILLING ADDRESS E] <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Diredlon Slmel Name Cil Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Slreel Name <br /> CITY STATE ZIP <br /> PHONE#IEXT• APN# LAND USE APPLICATION# - <br /> -a <br /> PHONE#2 EXT- BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR �I <br /> R.EQUESTOR CHECK If BILLING ADDRESS y14I <br /> mea <br /> BUSINESS NAME , PHONE# EXT. <br /> U CSO �i a � t^s Ty-\C ► - 15 33 <br /> HOME Or MAILING ADDRESS F # <br /> S 091 <br /> CITY1--) C STATE CL ZIP ` O <br /> I3ILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTIi 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. a't <br /> APPLICANT'S SIGNATURE: �_QDATE: C�I - 2 <br /> < -0y <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/MANAGER ❑ OTREIt AUTltonizED AGENT <br /> /f APPLICANT is of to 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 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: JT PAYMENT <br /> COMMENTS: <br /> SEP 2 2004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: q I EMPLOYEE <br /> Date Service Completed (if already completed): SERVICE CODE: r O PIE: n^ - <br /> Fee Amount: Amount Paid Payment Date CI y U <br /> Payment Type L� Invoice# Check# Receivbd B) <br /> EHD 48-01.025 SERVICE RE <br /> REVISED 6-5-02 1 <br />