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SAN JOAQUIOOUNTY ENVIRONMENTAL HEALT'0EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />p SERVICE REQUEST # <br />OWNE OPERATOR <br />AN <br />CHECKif BILLING ADDR S <br />FACILITY NAM—`_,-_ % <br />, <br />F`W <br />SITE ADDRESS�7a p � <br />Street Number <br />� <br />Direction <br />U�� � <br />Street Name _ \ <br />Cit <br />Cj` <br />IZi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />1 ) <br />APN # <br />SERVICE CODE: <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />Fee Amount:- - -7 C, U <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE RE, QUESTOR <br />REQUESTOR <br />f <br />CHECK If BILLING ADDRESsEl <br />BUSINESS NAME <br />PHONE# <br />z0,1 <br />EXT. <br />)6164-23= <br />HOME or MAILING ADDRESS <br />EMPLOYEE M <br />FAX # <br />DATE: ! 2-1-7 CI <br />ASSIGNED TO: V V Pi P-Lkt E- <br />EMPLOYEE #: cf;-3'7 <br />CITY \ <br />STAT,6--Aqt=, <br />ZIP '?T2 -,C <br />i <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 />OUNTY Ordinance Codes, Standards TATE and FEDERA w <br />P LICANT'S SIGNATURE: DATE: R 1 ' <br />PROPERTY/BIISINFSSOWNER❑ OPERATOR/ MANAGER xr OTHFit AUTIIORIZEDAGENT <br />❑ <br />If APPLICANT is not the BILLING P,RTY_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 />informatioh 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: L, _,97- A --A i c, <br />f <br />COMMENTS: <br />rpAYMEW <br />` W <br />DEC • 7 2004 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />ViEALTH DEPARTMENT <br />APPROVED BY: O L-1 k- EzE 4A <br />EMPLOYEE M <br />DATE: ! 2-1-7 CI <br />ASSIGNED TO: V V Pi P-Lkt E- <br />EMPLOYEE #: cf;-3'7 <br />DATE: ( 7 C,1 <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P 1 E: �3 C) /0 <br />Fee Amount:- - -7 C, U <br />Amount Paid <br />-F <br />Payment Date <br />Payment Type <br />Invoice # <br />Check #O <br />Received By: <br />EHD 48-01-025 <br />REVISED 6-5-02 <br />( f <br />SERVICE REQUEST FORM V <br />