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NAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> 1::[Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -aS s <br /> OWNER/ OPERATOR <br /> T�-F—�T CHECK If BILLING ADDRESS <br /> FACILITY NAME AA -PPI/I 6 Z <br /> SITE ADDRESS lJ/fi3� ` �/�1G "7�y1� (1�` r1 Y�.� `�J�fj�/� � 7 7 <br /> Stree Number Direction J—" LJV Strele`t Name J �1l vCi Zi Code <br /> HOME orM7AILIN'GADDRESS (If Different from Site Address) <br /> '9,6 0 I Street NumberT Street Name <br /> CITY lZA STATE C'4 Zip -3, 3-7 —1 <br /> a-r <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( "q ) 30 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( moi S77 -�( �l � <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �2 CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY _ STATE C_ ZIP /5'3'7 7 <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 /> 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 be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ' �� DATE: C - <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGER ❑ 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. E <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> a SAN JOACIUW COUNTY <br /> EN�IRONMENTA� <br /> vieAITH DEPARTMENT <br /> ACCEPTED BY: 0 L �i EMPLOYEE#: C,3 DATE: <br /> ASSIGNED TO: EMPLOYEE#: �v I' DATE: `3 /3 Q <br /> Date Service Completed (if already completed): Z. SERVICE CODE: r\ P 1 E: �i <br /> Fee Amount: flAPay <br /> mount Paid "1 m meent Date I b <br /> Payment Type Invoice# Check# 3�3— Received By: �- <br /> EHD 48-02-025 ,SR FORM(Goiden Rod) ` <br /> REVISED 11/17/2003 <br />