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SAN JOAQUI OUNTY ENVIRONMENTAL HEAL"SPEPARTMENT <br /> k 11 SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 31 Sho3 � <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME A(w I f� <br /> SITE ADDRESS "'7 (J®r � ^'� "f1�♦'�� fc (� �� (�.�'l <br /> Street Number Direction � Street Name 1 CI FZ11pCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CA <br /> _ 44 <br /> /t r1 u- )� /Cs o`� CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME �' �}_1 0! l PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY Aseg ZIP 07 S <br /> l 1 t,1. 0--AC 1 <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 /> COUNTY Ordinance Codes,Standards, STATE FEDERAL laws. q <br /> APPLICANT'S SIGNATURE: DATE: / ,` <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT� AU Q N <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: ��Y <br /> COMMENTS: RECEIVED <br /> SEP 2 4 2003 <br /> SAN JOAQUIN COUNTY <br /> ENAP1^B 11 HEALTH.SERVICES <br /> APPROVED BY: EMPLOYEE#:•; DATE: <br /> ASSIGNED TO: EMPLOYEE##: S ® DATE: R , ? <br /> Date Service Completed (if already completed): SERVICE CODE: ` PIE: r1 3 "1 D <br /> Fee Amount: �--� Amount Paid 7C� _ Payment{Date <br /> -7 <br /> Payment Type Invoice # Check# 25 Received By: <br /> 419 <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />