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SAN JOAQUOFOUNTY ENVIRONMENTAL HEALOEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> &a,b 'bNon, �d <br /> OWNER PERATOR CHECK if BILLING ADDRESSuvam Pforhio-15 <br /> ❑ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> v Street Number Direction Street Name 1 `HM 1 "'Glt Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) {(J��JJ <br /> \I Street Number �Stree Name "lam <br /> CITY ri TATE ZIP <br /> kuw) ( <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# �1I <br /> PHONE#2 1� BOS DISTRICT LOCATION CODE <br /> z-- l! CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR f CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# x <br /> / L �GJ� <br /> HOME or MAILING ADDRESSFAX# <br /> �C�� 1GU r �• l-693y")-- <br /> CITY =A STATE ZIP q5005, <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 thi plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standarrs, TAI � I:DERAL 1 <br /> APPLICANT'S SIGNATURE: ,Lj �l DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR i MANAGER ❑ OTIiEIi AUTHORIZED AGENT C <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tide <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 COUN-rY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> % A t1XV <br /> V-91 IV 9 <br /> TYPE OF SERVICE REQUESTED: ECE1V En <br /> COMMENTS: ZOO <br /> SAN JOAQUW COUNN <br /> NEZVO DEPP,MEN <br /> T <br /> APPROVED BY: EMPLOYEE#: �G DATE: —7-2 o-04 <br /> ASSIGNED TO: , J -- EMPLOYEE#: ! DATE: <br /> Date Service Comp ted (if already completed: SERVICE CODE: ,C 7 P i E: 6?3 <br /> Fee Amount: Amount Paid y�? Payment Date 'O <br /> -7 <br /> Payment Type Invoice# Check# FL-71 Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 0-5-02 <br />