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SAN JOAQUIN 4UNTY ENVIRONMENTAL HEALTH i PARTMENT <br />SERVICE-.tEQtJEST <br />Type of Business or Property FACILITY ID # <br />BUSINESS NAME�— ,� / Tjl /r <br />SERVICE REQUEST # <br />Hoor AI INGADDRESS <br />God Or e 17 O <br />FAX# <br />(dv 1317 <br />CITY �^yR STATE , zip <br />OWNER /OPERATOR <br />p ( I � <br />CHECK if BILLING ADDRESS <br />► i L V r ® G <br />DATE: 1,13 <br />FACILITY NAME �� M I M !f� m rt - <br />SITE ADDRESS <br />3 <br />P ! E: 3 6 <br />' rrA C ` <br />"V <br />Amount Paid <br />Payment Date / t to O3 <br />Street Number <br />Direction <br />Check#. � �® <br />CtWX537 <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />&treat Name <br />CITY <br />STATE ZIP <br />PHONE #1 ExT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #Y ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK If BILLING ADDRESS O <br />BUSINESS NAME�— ,� / Tjl /r <br />PHON E # — EXT' <br />Hoor AI INGADDRESS <br />God Or e 17 O <br />FAX# <br />(dv 1317 <br />CITY �^yR 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 <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 application and that the work to be performed will be done in accordance with all Sf JO UIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws.j ���� r <br />APPLICANT'S SIGNATURE: (/�li t-+�1�D�2 S/etc- c DATE: Z 30 <br />3 <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ® PrQ le <br />IfAPPLicANT 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. s ,� <br />TYPE OF SERVICE REQUESTED: / <br />PA V ED <br />COMMENTS: <br />D�� 1 2003 <br />SAN 30A0�31N COUNN <br />VOONMEINTAL <br />HEpL.TN DEPARTMENT <br />APPROVED BY: <br />EMPLOYEE M / <br />DATE: Dj <br />ASSIGNED TO: <br />EMPLOYEE 0 <br />DATE: 1,13 <br />Date Service Completed (if already completed) <br />SERVICe CODE: f� �i' <br />P ! E: 3 6 <br />Fee Amount: <br />Amount Paid <br />% 9cV <br />Payment Date / t to O3 <br />Payment Type t/ <br />Invoice # ``. <br />Check#. � �® <br />Received By; <br />EHD 48-01-025 SERVICE REQUEST FORM <br />REVISED 6-5-02 <br />