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.JAIN JUAQUIIN k-,0U1N 1 Y EIN VIRU1N1VIEN'IAL HEALTH 11 'YAR11VIEIN l <br />1 <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />G ; c,(- i' A �00 © s40 S Q o 33 0 <br />OWNER / OPERATOR <br />CHECK If BILLING ADDRESS ❑ <br />FACILITY NAME <br />SITE AD6I21=55 1 �ri "1 Tt <br />�.? y <br />t Stre, Number Direction St et Name Cit Zi Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 E;7 APN # LAND USE APPLICATION # <br />Qo`1)3b$ y -I2 <br />PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR \ <br />���� , \ � CHECK if BILLING ADDRESS <br />BUSINESS NAME )t 1 � 11 ' ��� c209 y 6l - 6-63DEXT. <br />HOME Or MAILING ADDRESS �, t W C— <br />CITY VO C�IL�o STATE Ccs ZIP 9 S 2 - <br />BILLING <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, Stand ds, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE:, DATE: <br />PROPERTY/ BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT w\� <br />If APPL/CANT t not t e BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO REL SE 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. _ ,/N (1FNT <br />TYPE OF SERVICE REQUESTED: f ( a (� <br />R�1 <br />COMMENTS: <br />`ZOO <br />�nn <br />H!� <br />CO <br />pU1N V CES <br />5AN JOAEP`TNSER O�V�S10N <br />EN`nRONME TPLNEP�iH <br />APPROVED BY: J <br />EMPLOYEE M �� 2 <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already ompleted): <br />SERVICE CODE: <br />P 1 E:. <br />Fee Amount: `Z <br />Amount Paid <br />�--� _ <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # /q7-7 <br />Received By: <br />EHD 48-01-025 <br />REVISED 6-5-02 <br />SERVICE REQUEST FORM <br />