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SAN JOAQit"N COUNTY ENVIRONMENTAL HEAL"'* DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ O ERATOR <br /> P70 j I CHECK If BILLING ADDRESS E] <br /> FACILITY NAME <br /> SITE ADDRESS <br /> L VSttreet Number Direction J 1 (� Street Name Cit (J Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> c ) Q W 1 bQ 4- 3 " I ++-- <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONT;ZACTOR / SERVICE RE, QUCSTOR <br /> REQUESTOR r CHECK if BILLING ADDRESS L_I <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAx# <br /> P. 0, 110 -��J c2 1) �i31-444 <br /> CITY / i�10411 !_4STATE ZIP qg�)36 <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 HHALTIi Di:I'AR'I'Mi-N'I'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,Standart1s,S"rA'1'1 $Dd FI-DCRAI.laws. <br /> APPLICANT'S SIGNATURE: l DATE: �k, <br /> PROPERTY/BUSINFSS OWNER❑ OPERATi MANAGF OTlirit A11TIloRIZFD ACFNTI v <br /> If API'LIC'ANT is not the BILLING ARTr proof of authorization/o sign is required Title <br /> AunfO 2IZATION 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 COUN-rY ENVIRONMENTAL HGALTI I DEPARTMEN'r as soon as it is available and at the same time it is <br /> provided to tile or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> RECEIVED <br /> AUG 212003 <br /> SAN JOAQUIN COUNTY <br /> UBLIC HEALTH SERVICES ISN <br /> APPROVED BY: ,l' EMPLOYEE#: 2ENVI ATE: S—")-1 -03 <br /> ASSIGNED TO: EMPLOYEE#: SCrO DATE: �, L+ - -673 <br /> Date Service Completed (if already completed): SERVICE CODE: 3 i S PIE: 2 603 <br /> Fee Amount: , Amount Paid Payment Date 8 z <br /> Payment Type Invoice# Check# (off Received By: ZXIL <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> RFVISFD G-5-0? <br />