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SAN JQ QU..: G OUNTY ENVIRONMENTAL HEAL. DEPARTMENT <br /> . :' <br /> SERVICE REQUEST <br /> Type of Business or,Property FACILITY 10# SERVICE R1=QIJESI# <br /> f Seo <br /> OWNER I OPERATOR <br /> -�s CHECK if BILLING ADDRESS O <br /> FAcwy NAME <br /> SfrE ADDRESS ll�i'� ty ir, ti <br /> Street Number Dinttelon Street Name Gi bZip Code <br /> HOME Or Ifti N.ADDRESS (If Different from Site Address) <br /> Street Nurnber <br /> -:.Street Name- <br /> CITY. <br /> STAYS ZIP <br /> PHONE## T• APN#' LAND USE APPucAnoN# <br /> PaONE ,� EXT. SOS.DISTRICT LOCATION CODE <br /> L/ <br /> CONTRACTOR[SERVICE REQUESrOR <br /> REQUESTOR <br /> 64e,/ CHECK if BILLING AoDRES91 <br /> BUSINESS NAME N Err. <br /> HOME or 1AAIUNG ADDRESS fAx# <br /> Clry <br /> STATE- ZIP <br /> BILLING.ACKNOWLEDGEMENT: 7, the undersigned,property'or business owner,.operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIWNMENTAL HEAL.THDEPARTM <br /> ENT 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.1 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 /> f <br /> .APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINRSS OWNER❑ 4%.-TOR/MANAG OrHar t AuTuoRaED AGENT, <br /> IfAPPLrCANT is not eBJTU"GPARTY,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 environmentallsite assessment <br /> information to the.SAN JOA.QUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as.soon'as it is available and at the same time it is <br /> provided to me or my representatiye. <br /> TYPE OF SERVICE REQUESTED: - �♦frrL►dw,�:. � �� 6 � .e��i• <br /> COMMENTS i <br /> ttiCCEPT a BY: EMPLOYEE F: f DATE: 1r <br /> (0 b U <br /> ct <br /> ASSIGNED TO: EMPLOYE#: DATE: <br /> EMPLOYEE.#. <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: ' <br /> z . <br /> Fee Amount. j AmotPay <br /> nf Paid ment Date <br /> .. <br /> Payment Type " Invoice# Check# 0�07� Received By: v <br /> .i <br /> TS. ,i„ ..�,'F,: ..•v ..5`".. t •`• .f t - "":- '-e c. . <br /> :. _•_ c , <br />