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SAN,JOAQUIN ' UNTY ENVIRONMENTAL HEALTIWI'ARTNIENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS t CA V"J V,iL�J fJT— <br /> �� <br /> Street Number Direction Street Name cityZi 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 /> U10 <br /> PHONE#2EXT. BOS DISTRICT LOCATION CODE <br /> ( ) 4u 1 -f z44- - <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �`G •,! 1^��J7 CHECK if BILLING ADDRESS <br /> BUSINESS NAME ^^ / PHONEx#� EXT. <br /> _ <br /> 1 \ j tOtC� C7t►Z� <br /> HOME or MAILING ADDRESS FAX# <br /> CITY C _ 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 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/rformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FtDERAL laws. <br /> APPLICANT'S SIGNATURE: �' DATE: <br /> PROPERTY/BUSINESS OWNER <br /> /'ri OPERATOR/MANAGFR ❑ OTHER AUTHORIZED AGENT❑ <br /> If ADPL/CANT is not the BILLING PARTY,Proof of to i ation 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 /> V NI <br /> TYPE OF SERVICE REQUESTED: C <br /> COMMENTS: ,1 v f <br /> SAN JU NSP SN <br /> p�61�C �fal'i�P� <br /> S NVIR�NMFN <br /> APPROVED BY: -td EMPLOYEE#: �, L' DATE: U <br /> ASSIGNED TO: / LI EMPLOYEE#: DATE: <br /> Date Service Comple d (if already completed): SERVICE CODE: V ? P/E: DC7 <br /> Fee Amount: Amount Paid �� �p Payment Date <br /> Payment Type Invoice# Check# l jo Received By. <br /> EHD 48-01.025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />