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SAN JOAQUIP .1UNTY ENVIRONMENTAL HEALT' XARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property :L- <br /> FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME I ,� n 4-k rs+ C'nr 9c <br /> SITE ADT—q� <br /> v` C- `J ?� <br /> >� Street Name it 2iCodStreet Number irection <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> STATE ZIP <br /> CITY <br /> EXT. APN# t AND USE APPLICATION# <br /> PHONE#1 <br /> ( ) BOS DISTRICT LOCATION CODE <br /> PHONE#2 EXT. <br /> ( ) CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> PHONE# ExT. <br /> BUSINESS NAME r I Fon�r ' n !/'1P�r �l "C- l <br /> �l FAx# <br /> HOME Or MAILING ADDR S <br /> v AT tpt -7 J <br /> CITY , <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 HEALTI-t DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> 1 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,Stcuhrlards,STATE and FEDERAL laws. 3,/03 <br /> APPLICANT'S SIGNATURE: <br /> DATE: /�/ <br /> PROPF,RTY/BUSINESS OWNER❑ OPERA /MANAGER ❑ OTnFR AUTIIORI7_FD AGENT❑ Title <br /> IfAPPLICANT iS 1101 the Bl1.1,lN_ G P=ARTY,proof of authorization to Sigel is required <br /> AUTHORIZA,rION 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 /> ONMEN"fAL HL'ALTIi DEPARTMENT as soon as it is availa�bl�eand t,Oame time it is <br /> information to the SAN JOAQUIN COUNTY ENVIR <br /> provided to me or my representative. ,v`C\V <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: l (fin ,, �-�- ( �Y�_ (,00 <br /> IIJJSANstjAO t Ae�N QPR MENT <br /> H <br /> EMPLOYEE#: 1 ?/ DATE: /l 0b <br /> APPROVED BY: `�. 1 r� <br /> EMPLOYEE#: DATE: 1 l J <br /> ASSIGNED TO: `�^ CA— <br /> SER�CE CODE: <br /> Date Service Completed (if already completed): - <br /> Payment Date <br /> Fee Amount: <br /> Amount Paid � <br /> Invoice# j 2 3 Check# 12a I <br /> Received By.—,4,,L— <br /> Payment Type <br /> SERVICE REQUEST FORM <br /> EHD 48-01-025 <br /> REVISED 6-5-02 <br />