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?,2 q- 513 3 pp SAN JOAQUIN ('')UN'I'Y ENVIRONMENTAL HEAL'F1 'El'AR'I'MEN'l' / <br /> SERVICE REQUEST <br /> ENAmE <br /> roperty FACILITY ID# SERVICE REQUEST# <br /> / <br /> V CHECKH BILLING ADDRESS <br /> FACILITY <br /> SITE ADDRESS I ' C e <br /> Treat Number DI" '1on Street Name It <br /> HOME Or MAILING ADDRESS (If Different from SiteAddress) <br /> $Treat Name <br /> 8 0 8 2 1/,� Street Number <br /> CITY �� STATE zip <br /> ��S--b 3 2— <br /> PHONE#1 ETR. APN# LAND USE APPLICATION# <br /> ( ZaY ) 367-- 1706 -OZ 2-7J <br /> PHONE#2 EXT- BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CCHECK1181LLINGADORESSO <br /> BUSINESS NAME 1. PHONE# EXT. <br /> OF6gz AJ h6 367 — 17o6 <br /> HOME or MAILING ADDRESS FAX# <br /> ( ?of 3 � 7—/oar <br /> CITY STAT ZIP cl <br /> YS <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,Slandar ,STA and FEDERAL laws. 7 <br /> APPLICANT'S SIGNATURI DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER ALrrIIORPLIA AGENT❑ <br /> IfAPP(JCAN' is Not die/3/LL/NG PARTY Proof of authorization to Sign is required Tille <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: )a/L <br /> COMMENTS: SlC x/r�e1 UfAzz/}✓Y.f_ �� /�(Cce-�t� C� G��J.act J �G�tG� Y�� ��JED <br /> Zlz-r/o3 / 'jl�� �� ti0p3 <br /> n -.,, 1 r <br /> //riL6Esco7ji 4 F�� POS d S°Pv�EN oN <br /> !moo�iiN� (r7 D <br /> SP 0`�HE P`NEpySH� <br /> N� <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (it already completed): SERVICE CODE: j Z Z PIE: O� <br /> Fee Amount: s0 Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6.5-02 <br />