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' SAN JOAQUIN ( JN'I'Y ElNVIRONMI;N'I'ALHLAL'1'l A ARTMLN'I' <br />SERVICE REQUEST <br />Type of Business or Property <br />B NESS NpE <br />r '-16,6C FACILITY ID # <br />H or MAI ADDRESS <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />CHECK If BILLING ADDRESS I <br />FACILITY NAME <br />SAN jOH�AIiHStiR pN1S�ON . <br />HE.P�jN <br />ENVIR�NMENSA� <br />SITE ADDRESS t1Q 1 <br />Street Number <br />/ <br />Dlrecllon <br />/� idC��i,% 11-146-( <br />T t Street Name <br />t C�II/w <br />ASSIGNED TO: V;A! A N&TC <br />ZI Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />DATE: <br />Street Name <br />CITY <br />PIE, 230C <br />STATE ZIP <br />Amount Paid <br />PHONE #1 EXT. <br />( ) <br />Payment Date. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #Z EXT. <br />( ) <br />Received By: %`" <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />M <br />REQUESTIOR <br />CHECK if BILLING ADDRESS <br />B NESS NpE <br />PHONE# EXT. <br />H or MAI ADDRESS <br />FAX # <br />CIT E. STATE ZIP G1�'72-6 / <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 pr this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Wliq3airA, STATE/and <br />1dFFEDERAL laws. <br />APPLICANT'S SIGNATU > ��-�s� DATL: <br />I'l(Ol'I.."wry / BUSINI%S OWNL OPIiRATOR/ MANnceu OTIICR Aurnowzm) AGLNT ❑ <br />!f Aiwt lc, is Hot the B1l UNG PARTY, proof of aulhorization 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/silt 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: <br />COMMENTS: <br />l 4 2003 <br />a�, <br />� vN <br />SAN jOH�AIiHStiR pN1S�ON . <br />HE.P�jN <br />ENVIR�NMENSA� <br />APPROVED BY: ' <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: V;A! A N&TC <br />EMPLOYEE #: 6 <br />DATE: <br />Date Service Completed (if already completed): Z �" <br />SERVICE CODE: f 9� <br />PIE, 230C <br />Fee Amount: '16"-7 _ <br />Amount Paid <br />Payment Date. <br />Payment Type <br />Invoice # <br />Check #-� :1 <br />Received By: %`" <br />EHD 48-01-025 SERVICE REQUEST FORM <br />REVISED 6.5-02 <br />C9 <br />9 <br />