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SAN JOAQUIN C IN'1'Y LNVIRONMUNTAL HLeALTH '-';PAR'1'MLN'1' <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID If SERVICE REQUEST If <br /> OW /OPERATOR <br /> J O r CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number DIrecllon /^ !' SIr t Na CIItn Code C <br /> HOME Or MAILING ADDRESS (If Different from Site Address) /3�/ <br /> sL <br /> �` `Sifeet NllSbect Name <br /> CITY�a y C TE ZIP <br /> PHONE#1 EXT. APN If LAND USE APPLICATION It <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR �1^' <br /> CHECKIt BILLING AODRE55O <br /> BUSINESS NAME `V PH NE En- — <br /> HOME Or MAILING ADD R S FAx# M <br /> erre 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 N <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 r <br /> COUNTY Ordinance Codes,Standard TATE and FEDERAL laws. / 7 <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNIiR J - OPERATOR/ NAGER ❑ OTHER ALrrifORIZED AGENT❑ <br /> if APPLICANT is nor the BILUNG 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 environmentallsite 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: /j U iC1 4�i <br /> COMMENTS: ��,q�, , p/ S ??�C� r-�""-f RECEIVED <br /> JAN 10 2003 <br /> SAN JOAOUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> 1/1�2 63 E MENTAI.HCCLTH DIVISI <br /> APPROVED BY: EMPLOYEE#: DATE: / / L� -7 <br /> ASSIGNED TO: EMPLOYEE#; t (4S I <br /> DATE: <br /> Date Service Completed (u already completed): SERVICE CODE: PIE: lJ <br /> Fee Amount: - Amount Paid Payment Date <br /> Payment Type Invoice# Check# -,! Received By: fj <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />