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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQIFEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> EmgkFQI6 <br /> OWNER/OPERAT <br /> ����1e� Wpr ` <br /> �(a— CHECK If BILLING ADDRESS,� f+ V / <br /> FACILRY NAME -pacific, Min1 - a-4 <br /> i- iias <br /> SITE ADDRESS LI,S'I �r*.t.G l'�'1 C. �• V 1 U L�9 �' ' -! J�-+ / <br /> Street Number I Direction Street Namo Ci 'I Zi Code <br /> HOME or MAILING ADDRESS Ilf DI fP-ter++froml Site Address) b 26'� Cr®®�� i54 c-k- 6 rc,`4e, <br /> Street Number Street Name <br /> CITY A. STATE / � ZIP q52 -19 <br /> C2—I Q <br /> PHONE#1 [• EXT, APN# LAND US(E„APPP'iLICATION# J I <br /> (20q) 230 • II <br /> `HONE#2 95 i20 ) Err. BIDS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR '1�urKA.i®, c ®t nneLj <br /> . CHECK if BILLING ADDRESS <br /> BUSINESS NAME Vl u eriQeirlir P20 4-zol E>R. <br /> HOME or MAILING ADDRESS FAX# <br /> Jk5l L.t✓tterne� c 0-5S-&5 <br /> CITY 4� STATE CA zip 45 n <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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this applica' n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Coder,Standard..,ST and FE RAL laws �} <br /> 1NlNMffG7NATURE: <br /> PROPERTY/BUS/NESS OWNER BI`� OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign i..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 /> COMMENT$: <br /> APPROVED BY: EMPLOYEE : DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Data <br /> Payment Type Invoice Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />