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.FAUN dUAYuLN �—(JWN'l Y LiN V11CU1N1V1L1V'1AL 11LAL'1•r1 VEPAKI'MLN•l' <br />4 ; SERVICE REQUEST <br />CONTRACTOR / SERVICE RWUESTOR - <br />REQUESTOR 1 r " <br />CHECK If BILLING ADDRESS <br />e of Busines ; r Property <br />t, ? ' <' FACILITY ID # <br />a <br />,;:SERVICE REQUEST.'#, <br />HOME Or MAILING ADDRESS� <br />1 4.• g <br />/ <br />OWNER I OPERATO <br />CHECK If <br />BILLING ADDRESS❑ <br />FACILITY NAME 1 <br />3-2 <br />EADDRE S <br />,M <br />0P <br />� <br />on <br />CStreetNumber <br />ZI e <br />HOME Or MAILIKG ADDR SS (if Different from Site Address) <br />fr <br />Street Number <br />Street Name <br />CITY$TATE <br />t <br />ZIP <br />PHONNE�E#1 ExT• <br />APN # <br />I -AND USE APPLICATION # <br />PHONE #2 • <br />� <br />E*" S <br />T q.06 <br />Vy <br />.rs L�zC <br />CONTRACTOR / SERVICE RWUESTOR - <br />REQUESTOR 1 r " <br />CHECK If BILLING ADDRESS <br />BUSINESS NAM <br />Pk E EXT. <br />7 <br />sncl)33 <br />HOME Or MAILING ADDRESS� <br />FAX _# <br />/ <br />CITY STAT ZIP Cit <br />c <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 or <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, Standard , TATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE:_l�✓i/ DATE: 1 <br />I <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLING PARTYY, 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 />OCT2 42002 <br />P B JOAQUIN COUNT,; <br />FNVIRONMENAI HEAL hi I i <br />APPROVED BY:EMPLOYEE#: DATE> <br />1 3 � <br />ASSIGNED TO C ' EMPLOYEE # DATE <br />Date Service Completed (if already completed): SERVICE CODE:' L PIE , Ix <br />Fee Amount: Amount Paid } : .' Payment Date, � <br />Payment Type Invoice V. Check # Received By . <br />EHD 48-01-025 SERVICE REQUEST FORM <br />REVISED 6;5-02 <br />