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SAN .TOA U"`I 'a <br /> Q COUNTY ENVIRONMENTAL HEAL�DEI DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID#/ SERVICE REQUEST# <br /> 3 3��3 <br /> S <br /> OWNER/ OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME L t <br /> �t v� 01t/c <br /> SITE AD�JDRE'S_S/ r <br /> Streel Number Direction a serve/ Street Name Zip Code <br /> 33 <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 /> ( <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE RE, QUESTOR <br /> REQUESTO � CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT.� <<� 0 <br /> HOME or MAIL G ADDRESS FAX# c <br /> gr <br /> CITYrJ�b STATE/ ZIP Q <br /> I311AANG ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of Sallie, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL I-IEALT►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 Code.,•,Stctndartls,ST -,. and FEDERAL.laws. <br /> APPLICANT'S SIGNATURE: DATtE::� �-el-12 CD 3 <br /> PROI'EItTY/BUSINESS OWN Ell OPERA OR/MANAGER ElOTIIER AUTHORIZED AGENT <br /> if APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tide <br /> AUT11ORIIATION 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 ENVIRONMEN"rAL HEALTH DEPARTMEN"r 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: �/ AlIC <br /> r�(MENT <br /> COMMENTS: RE <br /> APR 1 7 2003 <br /> �v <br /> SAN 30AOUIN SRV CES <br /> PUBLIC NTALTHEP1-1H DIVISION <br /> VIRONME � / <br /> APPROVED BY: EMPLOYEE#: C/ DATE: 7 <br /> ASSIGNED TO: V �. L EMPLOYEE#: ( DATE: <br /> Date Service Complet (if already completed): SERVICE CODE P 1 E: 2300': <br /> Fee Amount: - Amount Paid (o ., Payment ate p 3 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 4W <br />