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-JA1N J0A(2U11N l.OU1N l Y L'1N VIRO1N1V1LiN I AL r1EALA H JJLFAK'11V1E1N 1' <br /> SERVICE REQUEST <br /> Ty,fi of r siness or Property oFOACII-g 10�#—i SERVICE REQUEST# <br /> i404 -- :1 �� S R�o�z`1 Z 3 <br /> OTE PERATOR � -04' CHECK if BILLING ADDRESS❑ <br /> J - 0 <br /> FACILITY NAME /7�, <br /> 4 <br /> SITE ADDRESS I �J <br /> 4 � <br /> Street Number Direction �—Street Name �� Zi Code <br /> HOME Or I NG (TS (If Different from Site Address) <br /> U1VStreet Number Street Name <br /> CITY ; ^ T IP <br /> Ift <br /> Pj#1 E.T. APN# LAND USE APPLICATION# <br /> PHON#2 EXT. 130S DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR J <br /> I CHECK if BILLING ADDRESS ' <br /> BUSINESS NAME ^� ' PHONE EXT. <br /> � _2A:x; <br /> HOME or MAILING ADDRESS �C FAX# <br /> VV 2 ) <br /> CITY �JPTE ZIPq�"7 <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 ap lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TE and FEDERAL laws. �7 <br /> APPLICANT'S SIGNATURE: !tu / DATE: / � n <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 environmentaUsite'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: ,/` ! ( i df o�I gFCfNED <br /> COMMENTS: <br /> MAR 3 2003 <br /> SAN JOAQUIN COUNTY <br /> ENVIPUBLIC HEK�H ES <br /> RONMEN1M_HEALTTHIONISION <br /> APPROVED BY: EMPLOYEE#: `Z L� DATE: -3 3 <br /> ASSIGNED TO: A n� QEMPLOYEE#: �� DATE: `3 <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: 3 <br /> Fee Amount: 2�� Amount Paid '? Payment Date i� 316 3 <br /> Payment Type Invoice# Check# �_ Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />