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0AL1N .J"11VU1;V l-llUIN 1 1 1 LVI IN 1 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> v sfwfion I=A 0ou 3 � (2 SR0o *313-19 <br /> OWNER/OPERATOR <br /> P,4 , 1 n O r' (L f� C ( CHECK If BILLING ADDRESS <br /> FACILITY NAME Co <br /> Sq1->;IU� <br /> SITE ADDRESS 1~I I I C y�S2r�1� /i'J !v'GIi'7�L'Call <br /> Street Number Direction / Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS P. <br /> BUSINESS NAMEln D�� n U v %e, PHONE# EXT. <br /> Co i M1 C ( 3 10 ) `7C 1 g 9 f <br /> HOME or MAILING ADDR SS FAX# <br /> CITY Q I t Ll�t n r '15-0 <br /> 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,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT 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: AfU <br /> U T <br /> COMMENTS: <br /> RECEIVED <br /> SEP3 02002 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMFN RAL HFAI TH PIV19ION <br /> APPROVED BY: EMPLOYEE#: Z Z DATE: 30 -;k <br /> ASSIGNED TO: EMPLOYEE#: S O V DATE: �l • 3o J oZ <br /> Date Service Completed (if already completed): SERVICE CODE: 16 P/E: <br /> Fee Amount: Amount Paid C� 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 />