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SAN JOAQUIt 'OUN'I'Y ENVIRONMENTAL HLAL, MIIARTMLNT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ._9 <br /> KOC)3 " <br /> OWNER/OPERATOR <br /> CHECK i4 BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS lJ 111f <br /> L�A <br /> ?�reeTNumber Direction ( Street Name I v Zin Code <br /> HOME Or MAILING ADDRESS (If Differei S) <br /> ember .Street Name <br /> CITY 1Z7 STATE ZIP <br /> PHONE#t �� "� PLANDUSELICATION#OLALd-1%1 <br /> PHONE#2 � 7 LOCATION CODE <br /> ( ) QCs . <br /> -VIN i nAk-i vn t �;r,,R JICE REQUESTOR <br /> REQUESTER / i CHECK if BILLING ADDRESS <br /> BUSINESS NAME) PHONE# E ' <br /> ,,( �,�-7- 3 1 <br /> HOME Or MAILING ADDRESS ^� �j -- � � }� FAX# <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 projector <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: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR(NI i NAGER ❑ O'r ER AUTIIORIZED AGENT❑ \� <br /> /f APPLICANT is net the BILLING PARTY,proof of authorization to sigh is required <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator ofescrty 1 d at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmen"L�al�t� essment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available apo* LI same.,;Wil:it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: - 14 <br /> COMMENTS: I CCi �- \l\ '-Q <br /> Cfl, <br /> 3/ <br /> APPROVED BY: EMPLOYEE#: ) � ` DATE: <br /> `,ud-Q `ti14- <br /> ASSIGNED TO: i Cl w P-L EMPLOYEE#: O C DATE: <br /> Date Service Completed (i already com eted): SERVICE CODE: <br /> Fee Amount:, �` Amount Paid "1-7 g _ Payment Date <br /> Payment Type Invoice# Check# `� Received By: � <br /> EHD 48-01.025 SERVICE REQUEST FORM <br /> REVISED 6-5.02 <br />