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SAN JOAQUI OUNTY ENVIRONMENTAL HEAL' -DEPARTMENT <br /> SERVICE REQUEST <br /> TypeBusiness or perty FACILITY ID# SERVICE REQUEST# <br /> a,� 0o� 3 3 � S � �� 34 !; 1 ,3 <br /> OWN (OPERATOR�-6p CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> G <br /> SITE AD <br /> D <br /> R <br /> ESS 9/�/7J r n apC <br /> Street Numher irection (:MC) hMaet flame / �`' CiF V/ Z /e <br /> HOME or MAILING ADDRESS (If Different from Site A ess) <br /> Street Number Street Name <br /> CITY 2&o—L STATE ZIP <br /> PHON #1 EXT. APN# LAND USE APPLICATION# <br /> 1 ) 3/ — A, <br /> PHONEJ2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTO <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME a�Mwj PHO 46,nI j 337 T' <br /> HOMEOr� rIN ADDR�$S F'�# 9) 4-0 _ W/ z �1 <br /> CITY `J �l' / STATE ZIP <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 projector <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, TATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: (-Ilamtkll &b DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> if APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE. INFORMATION: When applicable, 1, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical.dataand/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: 1 r to PAYM E N i <br /> COMMENTS: <br /> J U L 10 2003 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRnNMFNTAI H�F7ALTH MVISION <br /> APPROVED BY: i tl t , O J EMPLOYEE#: 22�Z DATE: !—• <br /> ASSIGNED TO: J v I ? ,,v EMPLOYEE#: y DATE: � —(C — -, <br /> Lp <br /> Date Service Completed (if already completed): SERVICE CODE: i PIE: z3 D <br /> Fee Amount: �] Amount Paid Payment Date <br /> Payment Type ` Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />