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SAN JOAQ- COUNTY ENVIRONMENTAL HEA' T DEPARTMENT <br />SERVICE REQUEST <br />Type pf Business or Property <br />L <br />FACILITY ID # <br />f, <br />SERVICE REQUEST # <br />�Lx �3 V CSV 1 O <br />��� _ <br />LA> C� G_L� l7 n <br />5�zo0 �Yc <br />OWNER I OPERATOR <br />HOME or MAILING ADDRESS <br />S <br />�^ C <br />C' �, Cl CHECK If BILLING ADDRESS <br />FACILITY NAME C Kee - <br />`161 6 `I <br />SITE ADDRESS /1� <br />c) 'e Ap,1 c n � <br />ZIP C p� <br />v F3 <br />APPROVED BY: ( <br />SlreleJJl Number <br />Direction <br />Street Name <br />Cit <br />d� <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Date Service Completed (if already completed): <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />Payment Date.119 -.D3 <br />APN # <br />LAND USE APPLICATION # <br />Qoci) <br />Received By: <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICTLOCATION <br />CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR y <br />L <br />PAYMENT <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME1 <br />V.Z <br />��� _ <br />LA> C� G_L� l7 n <br />PH NE# <br />j EXT. <br />1 �� <br />HOME or MAILING ADDRESS <br />S <br />t <br />SAN JOAQUIN COUNTY <br />FAX # <br />00c1) <br />`161 6 `I <br />CITY c -52 <br />STATE Q C., <br />ZIP C p� <br />v F3 <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 wilh 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 Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: CUuc,+,r DATE: <br />PROPERTY / BUSINESS OWNER OPERATOR / MANAGER ❑ OTHER AUTIIORIZED AGENT ❑ <br />if APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Tide <br />AUTI 0R17ATION 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, geotecluiical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMEN"rAL HEALTII 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: J <br />2 <br />PAYMENT <br />COMMENTS: J <br />RECEIVED <br />JUN 2 2003 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />APPROVED BY: ( <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />YEE #: c <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: , <br />P I M2 <br />Fee Amount:- <br />Amount Paid/ <br />— <br />Payment Date.119 -.D3 <br />Payment Type <br />Invoice # <br />Check # ), <br />Received By: <br />EHD 48-01-025 SERVICE REQUEST FORM <br />REVISED 6-5-02 <br />f3 <br />