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' SAN JOAQV COUNTY ENVIRONMENTAL HEAL DEPARTMENT <br /> SERVICE REQUEST 7 <br /> Typepf Business r Property ,�, ,'n^ ; FACILITY ID# SERVICE REQUESTUya <br /> # <br /> It,v►u <br /> V o©r i�" X12 u 035S 7, <br /> OWN IOPERATO;y2 <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME L U <br /> SITE ADDRESS <br /> ' I Street Number Direction tree[Name d ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number j J(�/L J �yt'rJeet Name <br /> CITY STATE zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHVE� 9 EXT, BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTITg, <br /> CHECK if BILLING ADDRESS <br /> BUSINESS E PH ` `/ 4AEXT. <br /> HOME or MAILING DDRESSt FAX# <br /> CITY 1, STATE ZIP <br /> BILLING ACKNO LEDGEMENT: 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 plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar s, ATE and FED AL a <br /> APPLICANT'S SIGNATURE: /0 <br /> DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> 1f APPI.tCANT 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 th <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 HEALTIt DEPARTMENT as soon as it is available and at the same time it i <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Cjr `iJ�" PAYMENT <br /> p <br /> COMMENTS: <br /> OCT 9 2003 <br /> SAN JOAOUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> i NVIRONMENTAL HEALTH DMSION <br /> APPROVED BY: EMPLOYEE#: ..� DATE: <br /> ASSIGNED TO: J��// EMPLOYEE#:9 ? /1 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: /�g� P E: <br /> Fee Amount: '1 OO Amount Paid 0 Payment Date Q <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />