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�JAAIv .I eJAk4ULIN <.V UIN 1 Y l.'IN V110JIN1VIL4 IN'tA-L r1.EA-Lf1i)JEFAIi'I'MEf'NT <br /> SERVICE REQUEST <br /> TY ,®f Business r roperty FACILITY tD# SERVICE REQUEST# .1 ryF" <br /> .., 'bJrt ��,�Ci� <br /> ff'�eai A^k I y � �. st r--rr4y Ire f <br /> `,�, .,Y♦;�.:. ,itr ,s ..yl I nf� <br /> ,x Wy_ 1: 3.,. 1 �..;-i+P ,w7",f+�•r�Y aji.ytflA�! ' <br /> ' OVY R/OP oR <br /> f CHECK if BILLING ADDRESS <br /> FACnm NAME <br /> SITE ADD SS <br /> r Street Number] ,Di i n S ame Cod <br /> HOME or MAILING SS IDI Brent from Stt dress) <br /> F Street Number Street Name <br /> CITYis <br /> TATE ZIP <br /> PHONE# APN# [AND USE APPLICATION# <br /> r <br /> PHONE ' BOS BISTRICT �' tr tY�''°ti LOCATION CODE <br /> LK <br /> 5 �§ <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTO <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NA PHON <br /> HOME or MAILING ADD FAx# <br /> ' ) `. <br /> CITY TE ZIP <br /> BILL G 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 pplication and that the work to be performed will be done in accordance with all SAN JOAQUIN , <br /> COUNTY Ordinance Codes,Standar T d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the B L NC 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 /> R-.. TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> A . <br /> APPROVED BY -r r K t . <br /> EMPLOYEE j , DATE' >' <br /> ASSIGNED TO r x .a,t <br /> EMPLOYEE xi DATE_ d <br /> r <br /> Date Service Completed (if already compteted):. SERVICE CODE, <br /> Fee Amount: .Amount Paid <br /> 2-16 <br /> F. Payment Date <br /> y <br /> Payment Type 7T <br /> 8nvotce# - Check# Received By ' <br /> EHD 48-01-025 SERVICE REQUI}$T FORM <br /> REVISED 6;5-02 <br />