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SAN JOAQUIN LINTY ENVIRONMEN'rAL HEAL'►'. EI'AR'I'NV1EN'I' <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FA 0000 i" [SEQD32- l i 3 <br /> OWNER/OPERATOR _V <br /> CAU F Fos[,,s(/J , �Y 'L F J IN CHECK if BILLING ADDRESS <br /> FACILITY NAME `1 /F—R EXPC (RJ �u r<e 1 <br /> SITE ADDRESS { 3 �n \ cc �m l 1,E N�� n <br /> 1 Street"►Number Dlrectlon 7 Street Name -T AA A CIt n ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLINGADDRESSE] <br /> BUSINESS NAME�i I, I I6iN C J„ r pH'i 33 <br /> 7 EXT. <br /> HOME or MAILING ADDRESS \J J G FAX# <br /> CITY Th, <br /> `0 V STATE C . ZIP r,S-ZL 5 <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 ST TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DnTL: <br /> c — <br /> PROPERTY/BUSINESS OWNER C1 OPERATOR/MANAGER OTHER.AUTHORIZED AGENT <br /> If APPLICANT is not ofe BILLING PARTY.proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELLASE 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: Vf r c4 G / <br /> COMMENTS: <br /> APPROVED BY: \i V EMPLOYEE#: Z L L DATE: Z -G L, L <br /> ASSIGNED TO: J I� EMPLOYEE#: �C DATE: I - (.i1✓CZ/ <br /> Date Service Completed (if already completed): SERVICE CODE: i(� P/E: Z V <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type t/ Invoice# Check# — Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />