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SAN JOAQUIN ('-NUNTY ENVIRONMENTAL HEALTI' '1EPAR'I'MLNT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID If SERVICE REQUEST <br /> OWNER/OPERATOR <br /> _ CHECK it BILLING ADDRESS <br /> Er <br /> FACILITY <br /> SITE ADD ��11'rL-Q,�(�` r l Its Y✓�P/vt I s <br /> 11, reel Number I Direcllon I Slrc t Na CII ZI Cotle <br /> HOME -MAILING ADDRESS (If Different from Site Address) <br /> Street Number Stmet Name <br /> CRY STATE ZIP <br /> PH__ONE��ff1 ExT• APN# Q LAND USE L}}f�AT )N If13 - <br /> q <br /> ( 1 ) - 3,52-3 <br /> PHONEC2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> .4o - CHECK It BILLING ADDRESS <br /> BUSINESS NAME 1 ' PHONE# En' <br /> c7, , a-- Assv t a-k) I <br /> HOME or MAILING ADDRESS FAx If <br /> l YVU2YZt2 # ) 36 014p)) -72-2 _& OO <br /> CITY `1 `1I 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 Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: bW 141z DATE: ? lDD�J�,/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTUORizED AGENT 0-1-1- V <br /> IfAPPLICAArr is not the BIL.UNG PARTY,proof of authorization to sign is required Tit! <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: <br /> COMMENT 3 R CEIVED <br /> (^��^'•'"�,niA'3 JAN 10 2003 <br /> / I c SAN NTY <br /> PUBLIC HEALTH SIN ERVICE <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: (O M� EMPLOYEE#: (f DATE:, t <br /> Date Service Completed (if already c mpleted): SERVICE CODE: 3 PIE: <br /> Fee Amount: �Seor- <br /> Paid Payment Date <br /> Payment Type ,. Invoice If Check# Received By: <br /> EHD 4"1-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />