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SAN JOAQ V COUNTY ENVIRONMENTAL HEA' t I DEPARTMENT <br /> e SERVICE REQUEST . <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> DK <br /> I OPERATOR ,/ <br /> V\ L- P NCr16� /C. C CHECK If BILLING ADDRESS <br /> ACIUTY NAME // �J z- <br /> P'tfr f GPC <br /> ITE ADDRES <br /> HOME or MAILQING ADDRESS (If Different from Site Address) <br /> Slreal Number / 1 V, / ��Slyde Nama �G� <br /> CITYf^5C A—L G� C-4-STATE ZIPq-5-S 2 v <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) 20 3 -1910 - 06 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR DE r tr I yh <br /> {} l CHECK If BILLING ADDRESS 1 <br /> BUSINESS NAME PHONE# Exr. <br /> -( �� ; f�� S ' c,,CA <br /> s �/ CSS 3 <br /> HOME Or MAILING ADDRESSl L) Ue C..l /1-e7 a-il � (Alt# ) <br /> CITY , n,-��¢_ ` L STATE CO- ZIP C?.,^ , SZ-1 <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 tome or my business as identified on this form. <br /> 1 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 /> OUNTY OrdillnnCt'COdeS,Slandnrds,STATE and FEDERAL laws. ' <br /> F o <br /> laPL1CAN7"S SIGNATURE: �� � DATtC-7 <br /> I'Moi-ERTY/BUSINESS OWNER❑ 1/ OPERATOR/MANAGER ❑ OTIIFR AUTHORIZED AGENT yL <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tide <br /> AUTHOR17.ATION 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 HEALTtt DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. N"( <br /> TYPE OF SERVICE REQUESTED: / �' i �bir— <br /> COMMENTS: <br /> W` ENNR NME¢P NE O H OE SION <br /> APPROVED DY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: N EMPLOYEE CQ�/ � DATE: S'a,;Z 7/ <br /> Date Service Completed (if already completed): SERVICE CODE: �'a2 PIE: <br /> Amount Paid Payment Date �/�2-1 <br /> Fee Amount: l <br /> Payment Type ✓ Invoice# r Check If `'?-73 Received By: /..Q <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 0-5-02 <br />