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SAN JOAQUI COUNTY ENVIRONMENTAL HEALT— "EPARTMENT <br /> SERVICE REQUEST <br /> Typ f Business o rope V FACILITY ID# SERVICE REQUEST# <br /> - � s <br /> OWN R/OPERATOR ` ol.� <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE DDRES /�` <br /> Street Number Direction , V `� Eder <br /> HOME or MAILING ADDRESS (If Diff ent from e-Address) <br /> �- ^ Milk Street Number Street Name <br /> CITY Poh f) I PA STATE go S <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> a)918'JU—g a <br /> PHONE#2 ExT• BOS DISTRICT7-7[LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ` <br /> / CHECK If BILLING ADDRESS <br /> PHONE# ExT' <br /> BUSINESS NAME / „ J� <br /> HOME Or MAILING ADDRESS / ,( FAX <br /> CITY /`L�, t �j STATE IP <br /> BILLING ACKNOWL DGE CMENT: 1, 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 a lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards T TE andY*DERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/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, 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: RECEIVED <br /> COMMENTS: AUG 2 2 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: I. L4 DATE: `0 <br /> ASSIGNED TO: I EMPLOYEE#: DATE: v <br /> Date Service Complete (if alre dy completed): SERVICE CODE: P 1 E: 0 <br /> Fee Amount, Qv Amount Paid Payment Date <br /> Payment Type ./� Invoice# Check# l d R ceive By: <br /> EHD 48-02-025Qntod)y : <br /> REVISED 11/17/2003 <br />