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SAN JOAQUIN COUNTY ENviRoNwNTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> -'Type of Business or property FACILITY ID# SERVIICC�E REQUEST/#,j <br /> � s L qd�'NLc t- �. 5 (9- UGI <br /> 211- <br /> OWNER/OPERATOR. CHECK if BILLING ADDRESS <br /> FACILITY NAME // <br /> �/c A/—/ 2—IAI 7V ell C. <br /> SITE ADDRESS �,t v, 7' <br /> Street Number I Directi.r. Street Name CI 21 Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 <br /> ExT APN# LAND USE APPLICATION# <br /> tz�sl 7,74. $0 P <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> /Om /frAov- <br /> PHONE# Ext. <br /> BUSINESS NAME C, 6 7/- /,TO o /? <br /> HOME or MAILING ADDRESS v FAx# <br /> STATE ZIP c��� �1J <br /> CITY .oniGi„v �ao�/,q C-4 <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 <br /> or 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 b performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �G— DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHO AGENT /t.l IWc- <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, 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. <br /> TYPE OF SERVICE REQUESTED: <br /> ` r <br /> COMMENTS: <br /> CJ�Q Gov <br /> �oPav\MEN- N� <br /> Sp,EN��N�EpPR� . <br /> APPROVED EMPLOYEE#: q cjCf DATE: q n <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P i E: ' <br /> Fee Amount; Amount Paida27/.t� Payment Date ' <br /> pe Invoice ' <br /> Check# tL Received By:LZ <br /> Payment Ty # -1 to�3 <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />