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W <br /> SAN JOAQU"PUNTY ENVIRONMENTAL HEALEPARTMENT <br /> r <br /> � <br /> SERVICE REQUEST <br /> Type Business or operty JA JP FACILITY ID# SERVICE REQUEST# <br /> OW P ATOR <br /> CHECK if BILLING ADDRESS <br /> 0V <br /> FACILIM &I <br /> SITE ADD/CRESS �/�l/ VT�Va(/(� <br /> V Street Number Direction ee ame �""Cit Zi Cod <br /> HOME or MAILING 6DDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> P,vq) 9�t7-a9 <br /> PHONE EXT. BOS DISTRICT LOCATION CODE <br /> 1/1 CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> ('�� <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAM PHO E EXT. <br /> HOME or MAIUN ADDRESS FAX# <br /> CITY /_ STATE ZIPQ__ke4 ?k1n1 <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 HEALTI-I 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 Corles,Standards,STAT nd FEDERAL laws. i /�®� <br /> APPLICANT'S SIGNATURE: — ° "`� L DAT • 6 <br /> PROPFRTY/BUSINESS OWNER 11 OPERATOR/MANAGER ❑ OTHER AUTHORIZED ADEN ❑ <br /> If APDL/CANT 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 HEALThi DEPARTMENT as soon as it is available an at the Same time it is <br /> provided to me or my representative. SAY IV 1 <br /> TYPE OF SERVICE REQUESTED: s i <br /> COMMENTS: Ju <br /> SAN JOA 0U ,S RNCES <br /> PUBLIC HTALHEALTH DIVISION <br /> ENVIRONMEN <br /> APPROVED BY: _,EMPLOYEE#: DATE:' <br /> ASSIGNED TO: EMPLOYEE#: DATE: i <br /> Date Service Completed (if already completed): SERVICE CODE: Y PIE: d <br /> Fee Amount: Amount Paid ft Payment Date �- <br /> Payment Type Invoice# Check# Received By: <br /> -7_ - <br /> EHD 48-01-025 SERVICE EQUEST FORM <br /> REVISED 6-5-02 <br />