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vu� v ��u►�� uviv t k L' Lv vttiVivlvll V tf1L xxL� 11 1IJL1'Altl'iv1LiV 1 r <br /> WSERVICE REQUEST 1 <br /> .Type of Business or Property, '.,�;;,�ACILITY-ID`#`'= '•o'cs'vll ' ': ! .:SERVICE REQUEST`# k <br /> l OWNER I OPERATOR <br /> rCHECK If BILLINO ADDRESS❑ <br /> FACILmr NAME <br /> 1 ' ` SITE ADDRESS <br /> e . <br /> Ireel Number ec I '`• r a <br /> a. ;.. <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> StreetNu or Streetlklame " <br /> CITY STATE ZIP <br /> PHONE#1 Exr• APN#, LAND USE APPLICATION# ✓ <br /> PHONE#2 ' Exr. <br /> ;.BOS'DISTRICT. ,SI. rCM.pq:l ;LOCATION'Cs <br /> CONTRACTOR/ SERVICE REQUESTOR ' <br /> S` REQUESTOR CHECK If 131LLINO ADDRESS❑ {' <br /> v , <br /> BUSINESS NAMEPHONE# Exr <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> E. 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 /> L <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/BUSINESSOWNER❑ OPERATOR/MANAGER ❑ OTHER AUTFIORIzEDAGENT❑ <br /> If APPLICANT is not the J)/CLING PARTY.proof of authorization to sign is required T1rte <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property.located at the'``y;^'� <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or cnvironmcntaVsite assessment <br /> • infornation 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 /> >•'`'r. .. COMMENTS: <br /> APPRbVED BY: F.MPLOYEE#: <br /> DAi� <br /> ASSIGNED TO J MPLOYEE�#: DATE' <br /> Dato Seivlce"Completed "(Ifalready completed): SEftY10E CODE' { t' <br /> �t Irl <br /> Poe <br /> Amount: ' Amount Paid= Payment Date "A 1� <br /> Payment Type.: Invoice.#;: 4 ,Check#," Received By <br /> l <br /> EHD 48-01-025 <br /> REVISED,Q.5-02 SERVICE REQ()WT FORM <br />