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SAN JOAQUD%' BOUNTY ENVIRONMENTAL HEALTJI-' EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# S RVICE REQUEST# <br /> . 5����� z Zib <br /> OWNER I OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME �1 <br /> SITE ADDRESS / 9 � <br /> ' j-7 Q I tr et t 2i Code <br /> I Street Number Direct[on <br /> r HOME or MAILING ADDRESS Alf Different from Site Address) <br /> U10Street Number 1 Street Name <br /> CE i STA E EP <br /> PHONE#; E-. ApN# LAND USE PLICATIO�1,#� <br /> r �1 4 <br /> PHONE#2 EXT' BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> t <br /> REQUESTO ` CHECK if BILLING,4D0Res5 <br /> BUSINESS NAME `J PHONE# Ezx' <br /> - <br /> 3DDI <br /> HOME or MAILING AD t FAX# <br /> 1 ( ) <br /> CITYSTF ZIP �l <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 ENvtRONMENTAL 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 performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar s STATE and FEDERAL lawSsLI� <br /> APPLICANT'S SIGNATURE: DATE: r /41, A <br /> PROPERTY I BUSINESS OWNER OPERATOR/MANAGE OTHER AUTHORIZED AGENT❑ <br /> IfAPPLiCANT is not the BILLING PAR 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 enviromnental/site assessment <br /> information to the SAN fOAQUCN 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: U Z C �ENr <br /> i COMMENTS: <br /> SAN <br /> 7r �n 5 <br /> ' <br /> �J �1iJ <br /> `OAQU! <br /> ENVN CQtJIjjY <br /> flEg <br /> IROL7H btpq�E�TAL <br /> ��/ �/`- -..,✓' _�cr'r "!l' 1. .� G.'7.2 G- G�c7 i;Y�:i M � <br /> ACCEPTEDBY' EMPLOYEE#: ` DATE: <br /> ASSIGNED T0: �- EMPLOYEE#: DATE: <br /> Hate Service Completed (if already completed): SERVICE CODE: P 1 0'71)Z <br /> Fee Amount: Amount Paid 4' r Payment date LP <br /> i - <br /> Payment Type Invoice# _ Check#1 _ _ r Received By: <br /> 14 LI <br /> ��'�! �7Zs'r.t�.. C ^"�r.rrvf?2'G _1'/.�:� :..-G..t..^El.�,'�(" /'�tri'.•-t�! 4 ~� : y,a x�..::,rk <br /> EHD 48-02-025 v r_ ,��frs RM <br /> REVISED 11/17/2003 <br />