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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> S I C ( 6,11 e,0 eL <br /> �} CHECK if BILLING ADDRESS <br /> FACILITY NAME ,l L t( <br /> SITE ADDRESS I �Lt ye-(A AJ (civ✓'t- 5 �, 104A <br /> Street Number I Direction I Street Name CI Zip Code <br /> HOME or MAILING ADDRESS If Different from Site Address <br /> 3 4 <br /> tree umber Z• S11 Street Name SD _ z/ <br /> CITY STATE ZIP <br /> r;l K c_ 5 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (it, Coq - dt Z5- <br /> PHONEY EXT. BOS DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR SERVICE REQUESTO <br /> REQUESTOR /q <br /> 1 v VA CHECK If BILLING ADDRESS <br /> BUSINESS NAME /� PHONE# EXT. <br /> C/l" rr- G h it,e- 431-r3 a �9 <br /> HOME or MAILING ADDRESS y FAX# <br /> ��� <br /> 31 q6 60( r. rr (116e ) 0/ -- 13 t <br /> CITY r ,", STAT ZIP f S/70 <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 <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 JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> 4yot <br /> APPLICANT'S SIG NATURE. �� f A <br /> ( DATE: q/6 �'�_ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT pf0'♦ /�4 <br /> IfAPPLICANT is not the BILLING PARTY,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: <br /> COMMENTS: <br /> APPROVED BY: EMPLOYEE#: DATE: <br /> ASSIGNEE)TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check # Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />