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CAIN J UA (2 U UN t- (I U IN I Y E iN V 11<U IN 1VILIN 1 AL H LAL 1 H L I' "A K I IV1 L' IN C <br />SERVICE REQUEST <br />Ty of Busine or Property �/j ;� <br />FACILITY ID # <br />SERVICE REQUEST # <br />_ <br />Is <br />A I <br />�Pr Db� �(� o I <br />Sid oe�.��6 � <br />OW ER / OP RIkTO <br />��J <br />CHECK IfBILLING ADDRESS❑ <br />F✓� <br />FACILITY NAM � • �� <br />ASSIGNED TO: d <br />SITE ADDRESS <br />EMPLOYEE #: , Q.�-� <br />/ct�' ' <br />DATE: S--1-3 <br />7 <br />V/ Street Number <br />Dimon <br />Street N e <br />Fee Amount: �`l6�% <br />ZIe <br />HOME or MAILIN ADD�`If Different from Site AddressL. <br />Payment Date_ _3 <br />Payment Type _ i <br />Invoice # <br />Street Number <br />Street Name <br />CITYi )m /)/-,A) <br />ST � ZIP 016602 <br />PHONE #i ExT <br />APN # <br />LAND USE APPLICATION # <br />gig) g 3 <br />PHONE 2- ExT• <br />' J <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR• <br />G CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONEW/ EXT. <br />(�f <br />HOME or MAILING ADDRESS/ <br />` i in <br />F <br />6/ & 2 <br />CITY r / �/1 STAT ZIP f; <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 9pplication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Struuimd STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: Iim lit Ii�l✓ DATE:Y-310 <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ul'��f�' LCr'vV <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 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: (JS j <br />j �('� �� <br />PAYMENT <br />COMMENTS: <br />FNVIR <br />RECEIVED <br />MAY 12W3 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />NVENTAL HEALTH DIVISION <br />APPROVED BY: <br />EMPLOYEE #: 2- b%2- <br />DATE: 5-11--.03 <br />ASSIGNED TO: d <br />EMPLOYEE #: , Q.�-� <br />DATE: S--1-3 <br />Date Service Completed (if already completed): <br />SERVICE CODE: Gl <br />P 1 E: X300 <br />Fee Amount: �`l6�% <br />Amount Paid <br />(0 7 Oy <br />Payment Date_ _3 <br />Payment Type _ i <br />Invoice # <br />Check # � <br />Received By:12 <br />EHD 48-01-025 SERVICE REQ1JFST FORM <br />REVISED 6-5-02 W -X <br />