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SAN JOAQUIN LINTY ENviRoNMENTAL HEALTI EPARTMENT <br /> SERVICE REQUEST , <br /> Type of Business or Property FACILITY ID# SERVICE REQU�T# . <br /> OWNER/OPERATOR II <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 6*7 WI"ST BerH At-41 RD{�D TRAc�t 7 �f <br /> Street Namber Direction Street Name citvZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SAME An �J-TH A©DRcsS Street Number Street Name <br /> CITY 111 STATE ZIP <br /> PHONE#1I EXT' APN# t-AND USE APPLICATION# <br /> (2Q9 ) 83,5---Scb- n PA-0�3---315 <br /> PHONE#2 <br /> i Eur. BOS,DISTRICT JLOCATION CODE <br /> 1 <br /> i CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CNr=cK if BILLING ADDRESS ` <br /> BUSINESS DAME Gl,1I PHONE# ' <br /> t s �.. r.�I►.��. - I � 3� <br /> HOME or MAILING ADDRESS FAX# <br /> 418 MA E�d PL t � <br /> CITY k STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> I acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed fo me or my business as identified on this form <br /> I also certify that 1 havke prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUI[N <br /> COUNTY Ordinance Cddes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: Jam) DATE:11 <br /> PROPERTY/BUSINESS O ER❑ OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT� t t" — • F 'A <br /> IfAPPLJCANT is not the BILLING PARTY,proof of authorization 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 /> TYPE OF SERVICE REQUESTED: ,v vto t �� PA 1V E❑ <br /> 5 <br /> COMMENTS: <br /> rtl ta cootm <br /> �04AP1 SOA MENTAL <br /> SEty��D�pA4iSMENY <br /> APPROVED BY: if V EMPLOYEE#: DATE: <br /> k <br /> ASSIGNED TO: EMPLOYEE#: DATE: _ <br /> Date Service Compl6ied (if already completed): SERVICE CODE: P 1 E-7F <br /> Fee Amount: Amount Paid :[ _ p Payment Date <br /> # Payment Type �/ Invoice# Check# 7-7f /received By: <br /> fEHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />