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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ERVICE REQUEST# <br />' <br /> OWNER/OPERATOR •J <br /> V1 q'4Z POKO-A CHECK if BILLING ADDRESS O <br /> FACILay NAME <br /> SITE ADDRESS 1 zN ' N�A ZA46 ZVNV6n Of SZ 36, <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'I EXT• APN# LAND USE APPLICATION# <br /> (2ryq) y' - sz�� oql- 3 -of PA 03-95 <br /> PHONE#2 EXT• 'BOS DISTRICT 3" LOCATION CODE <br /> i CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR b� �� � <br /> f / CHECK if BILLING ADDREslksm <br /> Bil$INESS IVAl1AEh p� � r„ I �U��J PHONE# ExT• <br /> HOME or MAILING ADDRESS rQ O FAX# o Z <br /> (2. ) <br /> CITY �a/' STATE C4- ZIP C?5-2-f I <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 la I <br /> APPLICANT'S SIGNATURE• DATE: ,Z I�-07 <br /> PROPERTY/BUSINESS OWN OPERATOR/ ER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT 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: <br /> COMMENTS: �aQ Ij <br /> RECEIVED <br /> l Z8`U'f/ <br /> aftl DEC 17 2003 <br /> 3 <br /> rJC1/�1�� SAN JOAQUIN COUNTY Q ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: EMPLOYEE#: 7 DATE: <br /> ASSIGNED TO: } EMPLOYEE#: DATE: 37 <br /> Date Service Completed (if already completed): SERVICE CODE: P!E O <br /> Fee Amount 69 Amount Paid Payment Date10 1 <br /> 1 t p <br /> Payment Type ,/ Invoice# Check# Q Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />