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SAN JOAQUV COUNTY ENVIRONMENTAL HEAL- DEPARTMENT <br /> ~ SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> c_-CD SPJ03 '-4-20 <br /> OWNER/O ERATOR <br /> l e �_b CHECK if BILLING ADDRESS <br /> FACILITY NAME . t <br /> r U.L <br /> SITE ADDRESS �IV^ /I uhr <br /> treeI Number Direction 1 Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Slreal Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> 1 , 051 - 090 - 15 E4 :V -L( 7 <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> t ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ^ CHECK If BILLING ADDRESS <br /> �e L <br /> BUSINESS NAME �• PHONE# J Ext. <br /> HOME orM ING ADDRESIS FAX# <br /> a V C <br /> CITY STATE ' ZIP <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 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 Cortes,Standards, ST TE at FEDEQn I S. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ PEILATOR INANAGER ❑ OTHER AUTHORIZED AGENT. <br /> if APPLICANT 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: SlAif 41 I1�- S 1,f,1,1J PP� NE� <br /> COMMENTS: to <br /> OS <br /> SPPN I\r k0 \00R BEV S\ON <br /> UB MEN1 P� <br /> PNS\PpN <br /> APPROVED BY: 'a , 'o EMPLOYEE M DATE: 1 - 2,- J <br /> ASSIGNED TO: V`^"^ EMPLOYEE M 5'3 6 DATE. Z ' <br /> Date Service Completed (if already completed): SERVICE CODE: tj 1,'j., P/E: <br /> Fee Amount: 1—)� Amount Paid 'LF I_1. Payment Date _l i- p 3 <br /> Payment Type Invoice# Check# 7/(J Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />