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SAN JOAQUI6OUNTY ENVIRONMENTAL HEALTOPEPARTMENT <br />SERVICE REQUEST V <br />Type of Business or Property <br />E FACILITY ID # <br />3 <br />3 <br />SERVIC <br />0 �) 3� <br />UEST # <br />q--- 4 5 <br />OWNER/ O` �ERATOR <br />in -Ar 0-� Wihrniaj <br />CHECK If BILLING ADDRESS❑ <br />FACILITY NAME L n I/ — 5 J T -E 300 <br />CITY / \ ' <br />STATE ZIP <br />SITE ADDRESS <br />Street Number I <br />Direction I <br />C©YYa1 40I OU <br />SERVICE CO/DE: <br />TyG ci <br />r7l5-3-G <br />Zip Code <br />—City <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Nur <br />! <br />Street Name <br />Payment Type <br />CITY <br />STATE ZIP <br />Received By: <br />PHONE #1 EXT. <br />c ) <br />APN # <br />' 119- o D 5 <br />LAND USE APPLICATION # <br />PHONE #2 ExT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR l <br />�J <br />CHECK If BILLING ADORES <br />BUSINESS NAMEpl <br />UC,T� C in ��' <br />COMMENTS: <br />l l� <br />EXT. <br />b -1—W <br />HOME Or MAILIN� S <br />EMPLOYEE #: �"L� <br />ATE: DIIVHON ? <br />1111 <br />CITY / \ ' <br />STATE ZIP <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 l have prepared this application and that the work to be performed will be done in accordance with all SA14JOAQUIN <br />COUNTY Ordinance Cortes, Standards, STAT d EI laws. 1 <br />APPLICANT'S SIGNATURE: DATE: `T — a3 ' <br />PROI-FRTY/ BUSINESS OWNER❑ O EI T It MANAGER ❑ OTHER AUTIIORIZED ACFNT ❑ <br />If APPLICANT is not the BILLING PANTY, proof of authorization to sign is required Title <br />AUTI-IORIZATION 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 HEALTII 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: U� r <br />COMMENTS: <br />l l� <br />HAYMENT <br />RECEIVED <br />APR 1 1 2003 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICFS <br />APPROVED BY: <br />EMPLOYEE #: �"L� <br />ATE: DIIVHON ? <br />1111 <br />ASSIGNED TO: <br />EMPLOYEE #: "") 3 YO <br />DATE: ' / / <br />Date Service Completed (if already completed): <br />SERVICE CO/DE: <br />PIE: 'L 3 <br />Fee Amount: 2(p2 <br />Amount Paid <br />! <br />Payment Date Y—//;- ,, , <br />Payment Type <br />Invoice # <br />Check # 3 7 <br />Received By: <br />EHD 48-01-025 SERVICE REQUEST FORM <br />REVISED 6-5-02 <br />