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12-AUG-2003 06:16PM FROM-CASCO +3148214162T-622 P.002/002 F-534 <br /> SAN JOAQNTY ENVIRONMENTAL HEALTEMTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> J � k it t� CHECK I7`BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number 111 ct on Straot Name city ZIP Cod <br /> HOME or MAILING ADDRESS (If LDifferent from Site Address) f�������� <br /> e g �� II Ir L- Straot Numhor. Street Narna <br /> CITY .. ...STATE �. ZIP <br /> PHpOO�NE#'1` EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 Ex-r. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# LxT. <br /> ctA f-I— I I cc 5Z <br /> HOME or MAILING ADDRESS FAX# <br /> DAP I ) <br /> CITY 1r_Ll STATE Mc ZIP / 1 <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 I•IFALTH DEPARTMENT hourly charges associated with this project <br /> or 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 JOAQUTN <br /> COUNTY Ordinance Codes,Standar STATE and FEDERAL laws- <br /> APPLICANT'S SIGNATURE: DATE: ti <br /> PROPERTY I BUSINESS OWNER OPEPkTOR/M,LNAGrtt © OTHER AUTHORIZED AGENT <br /> If APPLICr1JVT is not the BILLING PARTY,proof of attYhorization to sign is required Titic <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 LO 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 rcpresentative- <br /> tK <br /> YI G <br /> TYPE OF SERVICE REQUESTED: fi[11 L'17,4C.1 Cy I_.I H7-Cr{, MF—PA<,je-~p e-&N i✓*( r5U t-v-1 C rC�f� CAr.1 L f <br /> COMMENTS: <br /> 5 <br /> n 4 <br /> I♦ <br /> APPROVEDBY: EMPLOYEE#: 1 DATE: z <br /> t� t, <br /> ASSIGNED TO: EMPLOYEE#: / DATE: <br /> Date Service Completed (if alre y comp) tOd): SERVICE CODE: ' ) PIE: <br /> Fee Arno unt. Z� Amount Paid Payment Date <br /> Payment Type I Invoice# Check# Re eivad By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 5-5-02 <br />