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SAN JOAQICOUNTY ENVIRONMENTAL HEAL DEPARTMENT <br /> SERVICE'REQUEST <br /> [FACILITY <br /> pe of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OP RATOR _ n <br /> /�/r�'r7 / CHECK If BILLING ADDRE55� <br /> NAME �/ 2 /� <br /> SITE An <br /> (J .�gpf"Sb ZQ ( /7� S Or..ti (C� G <br /> Street Number Direction Street Namr / <br /> HOME Or MAIL-ING^ADDRESS (If Different from Site Address) cl zl Code <br /> -pie Street Number Slreel Name <br /> CITY STATE zip <br /> PHONE#I EXT. APN# LAND USE APPLICATION# <br /> c ) — -3--10 2 / <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS CD <br /> BUSINESS NAMMy-) PHONE# ExT. <br /> IT--) /(�1-I 5 /"�vr- <br /> HOME OrIPAILING ADDRESS - FAX# <br /> -Y-v — u SCD c ) � 34072 <br /> CITYIre r C, STATE ZIP in T5-zzff <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 HEALTIi 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: 2 / /liT DATE: <br /> ( z �' <br /> PROPERTY/BIININFSS OWNER❑ PEItAT012/MANAGER ❑ OTR pm AUTHORIZED AGENT tLt <br /> ([ <br /> If APPLICANT is no ILLINC PARTY proof of authorization to sign is rertuiret 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 environmentaVsite assessment <br /> informatiotl to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sante time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> �s°Ho"so� <br /> �-1'/TM"� Q, t�""� J'�smn'-Gaz[ �GCa�.K.cLS -NV\P Nn,AEN1 AE HEA <br /> APPROVED BY: EMPLOYEE M DATE: d <br /> ASSIGNED TO: EMPLOYEE M L DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Pi E: <br /> Fee Amount: Amount Paid gb_ Payment Date <br /> Payment Type Invoice# Cheek# L S-2,<'- Received By: <br /> EHD 48-01.025 SERVICE REQUEST FO� <br /> REVISED 6-5-02 <br />