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SAN JOAQW -)UNTY ENVIRONMENTAL HEAL`I'r - EPAR'TMEN`I' <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S�-C'O 3 (o(%-Z l <br /> OWNER I OPERATOR <br /> R, 9U, �✓ �,J�ST �� ` T J ` CHECK If BILLING ADDRESS <br /> FACILITY NAME () n ( \f <br /> �) 1l J 1 <br /> SITE ADDRESS %_ , N W C: CL S;J C tC —, J :� <br /> Street Number Direction Street Name City Zi 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# f) LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> h1/� l. � CHECK If BILLING ADDRESS <br /> BUSINESS NAME �� (\ PHON� EXT. <br /> rl u 1 <br /> HOME or MAILING ADDRESS FAX# <br /> 5u5 <br /> CAT AL t ,ti A 6%) 91 - 44 i <br /> CITY STATE C A ZIP a ('S <br /> S A C 1 A rv, cN <br /> BILLING ACICNOWI,EDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTI-I 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 Codas,Standards, STATE and FED I <br /> APPLICANT'S SIGNATURE: / <br /> DATEk)ll��� <br /> PROPERTY/BIISINFSSOWNER❑ OPERATOR/NIANAGEIt ElOTIIEItAUTIIORIZEDAGENT 41s1�y <br /> If APPLICANT is not the BILLING PARTYproojof«rrdrorizatiun to sign is regrrirer! Tarte <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 HEALTI-I 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: Lc)F— / 7 PAYMENT <br /> COMMENTS: Ht( )VED <br /> NOV 13 2003 <br /> SAN JOAQUIN COUNTY <br /> ENVI lt('1N,.I ENT^L <br /> HEALTH L jzpAm i -:NT <br /> APPROVED BY: CJL_t V ( , EMPLOYEE M Z I DATE: //' <br /> ASSIGNED TO: EMPLOYEE M / 3s.�Z DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ct k P 1 E: 3 G <br /> Fee Amount: c Amount Paid a 7 Payment Date f I c <br /> Payment Type Invoice# Check It Received By: <br /> <� <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />