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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTP-gEPARTMENT <br /> ' SERVICE REQUEST <br /> �- <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Po 79? <br /> OWNER 1 ePf12fUR <br /> CHECK If BILLING ADDRESS❑ <br /> FACllfl'Y NAME <br /> SITE ADDRESS <br /> Street <br /> lyN,u/m/ber Direct ion ) <br /> C[tv Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) J <br /> Street Number Street Name <br /> / <br /> CITY IIIEW <br /> STATE � Zip <br /> PHONE#1 /V/7 ExY• APN# r I LC+ L7 Z LAND USE APPLICATION At <br /> PHO E#Z _ EXT. BOS DISTRICT LOCATION CODE <br /> ( Sal �} -162z' <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR f�/� b4AXIOD k*4 ❑ <br /> �`�l CHECK If BILLING ADDRESS <br /> BUSINESS NAMEj�LI /Ln/ Pk # E� <br /> 110MEOrMAILINGADDRESS 2 r,n fi�� r)/ FAX# I <br /> CITY 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: _/L9�Q 3 <br /> DATE.: <br /> PROPERTY/BUSINESS OWNER P OPERA OR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ I <br /> IfAPPL.ICANT is not the BILLING PAS 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: so(;k Wt kL �e_ pVJ� rrrL.,.. P t^' C k e t&I, <br /> COMMENTS: , PAYMENT <br /> Nl�hire_ /1/1 CA,In wy e vie— P 1 u,,. f 9a''°3 CEIVED <br /> LL ido <br /> -OCT <br /> 0� SAN JOAQU1N COUNTY <br /> 1C HEALTH SERVICES <br /> APPROVED BY: `� �� EMPLOYEE#: WRONM -03 <br /> ASSIGNED 70: e S EMPLOYEE#: „ry (f DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> 5Z2, PIE: 4L102 <br /> Fee Amount: 14 do Amount Paid b Payment Date D l fl <br /> Payment Type ✓ Invoice# Check# Received hy: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />