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1% ' ' <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> qn(. J: x000 5u30 SKG038 g <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> l L <br /> FACILITY NAME <br /> SITE ADDRESS k U�j UU I ID,C)l 51 C ,L T <br /> Street Number Direction Street Name city Zip 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 /> ( I <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( l <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Ay^,� J(�� CHECK if BILLING ADDRESS© <br /> O'1 N 1V j�~ <br /> BUSINESS NAME ^^ r' PHO E lot I ExT. <br /> �1� <br /> OR <br /> HOME Or MAILING ADDRESS FAX# <br /> PAv I l ) <br /> CITY STATE ZIP \qs�- <br /> Cp ` � s.ti� `I <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 <br /> or 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 E laws. / <br /> APPLICANT'S SIGNATURE: C � DATE: Q_S_ (� 9 <br /> ]PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ACE,, , Fo 4 C , <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: L f S ( �'� i F 17 PAYM�N <br /> COMMENTS: <br /> £V 7 Co �. a r, <br /> l Ast Q,tiaD� <br /> MAY 7 <br /> SFE s Vo:�(oa�G► 2 2004 <br /> SAN JOPIOUIN COUNTY <br /> EN\jH pEPPTAL <br /> R MENT <br /> APPROVED BY: 0 <br /> EMPLOYEE#: 3 DATE: S Z 7 O <br /> ASSIGNED TO: ( L_ EMPLOYEE#: `JS C DATE: 2-'7 <br /> Date Service Completed (if already completed): SERVICE CODE: r 0.� PE- C) <br /> Fee Amount: til Amount Paid a / Payment Date S� D C f <br /> Payment Type L/ Invoice# Check# a33 Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />