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aw. <br />i v v ---) -z&r)t,,trt, I J Q,3 -o I c4 .1 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTF1 DEPARTMENT <br />SERVICE REQV <br />Typo a Business 0 P rt <br />BUSINESS NAM 1 <br />PHONE 9 ExT, <br />FAClL1TYID#. <br />FAx # <br />6W ) <br />SERVICE REQUEST O <br />bWNEk OPERATOR <br />CAN JOAQUIN COUNTY <br />CHECK if BILLING ADDRESSO <br />FACILITY NAME <br />f Vy <br />--i1TE <br />EMPLOYEE # <br />DATE: <br />ADDRESS <br />�b <br />.46Street Number <br />Direction <br />Street Name <br />City T <br />Zip Code <br />HOME Or MAILING ADDRESS (if Different from Site Address) <br />Street Number <br />P, E: QQ <br />Street Name <br />CITY <br />1A <br />-75- <br />STATE Zip <br />PHONE #1 <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />EX7. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAM 1 <br />PHONE 9 ExT, <br />HOME or MAILING ADDRESS <br />FAx # <br />6W ) <br />CITY. V Zip <br />BILLING ACKNQWLF,f)GEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTALHEALTH DEPARTMENT hourly charges associated with this -project or <br />ixtivity 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: DATE: <br />Omwi ho" xInf-a I i YL I,= <br />If APPLICANT is not the BILLING PARTY, proof of auth&ritalion to sign .is req.uh et Title <br />-o - <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the pr.per ty located at the <br />above site address, hereby authorize the release of any and all resuits,.geotechnical dataAand/or environmental/site assessment, <br />informatioh to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />movided to me or my representative. <br />TYPE OF SERVICE REQUESTED: F(,A-f <br />0111- PAYMENT <br />COMMENTS: <br />RECENtU <br />OCT 6 2011 <br />CAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />APPROVED BY: Z <br />EMPLOYEE # <br />DATE: <br />ASSIGNED TO: <br />EMPLOYiE #: <br />DA <br />Date Service Completed (if already completed): <br />SERVICECODE: <br />P, E: QQ <br />Fee Amount: <br />Amount .PaidO-D <br />-75- <br />Payment Date 0 <br />Paymdnt Type ........... y <br />Invoice # <br />Check Received By: <br />EHD 48-01-025 <br />SERVICE REQUEST FORM <br />