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zog— 6 yIf-31335 <br /> SAN JO Of IJFALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> qqc. ODD 0 —7 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME nn <br /> SITE ADDR <br /> a W* city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> w PHONE#1 \ ExT APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 ExT• BOS`D#STRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR N nn CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> 5 �,6vt G ti� . (' 2-13 3L/ 78 117 <br /> HOME or MAILING ADDRESS # FAX# <br /> 13�io PASS RD aS ( 213) -76/- /90 <br /> CITY CJ�.L u P STATE C�, ZIP C,qs�� <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 SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE ERALlaWS. ` <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT CAG E,%-T F,)4 C-- <br /> ,- T <br /> If APPLICANT 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. <br /> TYPE OF SERVICE REQUESTED: c S _ r- /`— gECFIVED <br /> COMMENTS: <br /> Q e c��, �� . ���� Q�ti 4 A 7 2004 <br /> 39 � MAY 2 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: 0C., C/E i EMPLOYEE#: (C S2 DATE: Jr- -Z (b <br /> ASSIGNED TO: EMPLOYEE#: DATE: 2 7 �i <br /> Date Service Completed (if already completed): SERVICE CODE: P E: U ' <br /> Fee Amount: �-79,,rl Amount Paid Aa 7 Payment Date D4 <br /> Payment Type Invoice# Check# Received By: <br /> SERVICE REQUEST FORM <br /> REVISED - - <br />