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O'AiN .JlJL1k2ULIN L,VU1V1 Y L' 1NV11i'UINiVI 1NlE1L11L'11 ,IY1 " 1'111tIAl 1V1 <br /> SERVICE REQUEST <br /> T*pe of Business orProperty FACILITY ID# SERVICE REQUEST# <br /> v . sfgt+f'Or) 00`0 3 � - SRO 0 -311)-fig <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS El <br /> �� \� wgod c t <br /> FACILITY NAME y-oj -A�A <br /> !-� J l O f' <br /> SITE ADDRESS M " E <br /> Mae)te <br /> �w <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number et Name <br /> CITY STATE Vit? <br /> c =�„ <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# ,f <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ �RVICE REQUESTOR <br /> REQUESTOR <br /> LI CHECK If BILLING ADDRESS <br /> BUSINESS NAME ���ClY n I �G( n �` ` PHONE# EXT. <br /> lY V� tel g",,..�,�:-• ��, <br /> b o 31 `7 '1 q q q I <br /> HOME or MAILING ADDR SS FAX# <br /> (I rl I ill 0o cI (3 10 ) q q , 4- <br /> L CITY <br /> 4- <br /> CITY a I -t LI_ n CA 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 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,Standa �,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: { <br /> �;Tti DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERAT0 QMR ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the I31LLING PARTY P f 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: V S T �I - <br /> COMMENTS: (J � /➢ <br /> RECEIVED <br /> / •J...1 � f C L <br /> SAN JOAQUIN COUNT'r <br /> PUBLIC HEALTH SERVICES <br /> ENVIRGN,,1-'NlAt HrAI TH RVI`str!N <br /> APPROVED BY: EMPLOYEE#: Z �� DATE: ?0 <br /> ASSIGNED TO: EMPLOYEE#: •7 5,V0 <br /> d 0 DATE: q - 3o -a <br /> Date Service Completed (if already completed): SERVICE C✓ODE: f(�6I PIE: <br /> Fee Amount: Amount Paid a �? Payment Date 3� <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br /> m <br />