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CAIN JVAQUEN k-VUtN1Y L1NVIRV1NME1NIAL11EALA HJWARIMEIN 1 <br /> SERVICE REQUEST <br /> Ty a of Busine or Property FACILITY ID# SERVICE REQUEST# <br /> sr<t'T 333 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 72-1 Street Number 4 Direction 0/ —"o Street Name CCi 7 Z ode <br /> HOME or M ILING ADDRESS (If Different from Site Address) <br /> l/J\ v x Street Number Street Name <br /> CITY TE ZI�,`l <br /> PHONE#1 EXT' <br /> APN# LAND USE APPLICATION#f7J �/L <br /> W) (?]a- OWL <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> r7-- <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ��� C <br /> CHECK if BILLING ADDRESS <br /> -ahaA=:� 4 <br /> BUSINESS NAM � &214-96 <br /> PHONE � _ � Exr. <br /> 6j�d) <br /> HOME or MAILING ADDRE FAX# <br /> CITY ST 'e ZIP <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 /> ctivity will be billed to me or my business as identified on this form. <br /> also certify that I have prepared this a Acation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, T TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: A'& Com) DATE: <br /> ROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <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, geotecluiical data and/or environmental/site assessment <br /> formation 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 1E NT <br /> TYPE OF SERVICE REQUESTED: EC— <br /> COMMENTS: <br /> SAN JOAQUIN S RV CES <br /> POBEIC N1A�jHEp v DNISION <br /> ENVIRONMEN <br /> APPROVED BY: EMPLOYEE#: 2& <br /> DATE: 1 <br /> ASSIGNED TO: EMPLOYEE#: 3 �/ DATE: i <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: Z <br /> Fee Amount: Amount PaidL-1 — Payment Date [f 0- <br /> Payment Type Invoice# Check# D�l/ Received By: / <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />