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3A1N JUAQUTA k.UUINTY LiN V1KUiNAlhiN1IAL t1EALIH 1)kAARTMENl' <br /> l � <br /> •• � SERVICE REQUEST <br /> T//y++pe.of Business or Property �+ FACILITY ID# SERVICE REQUEST# <br /> a4 ds <br /> OWNER/OPERATOR .y CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS Z 3(00 WGt P—A 0''f L—1 N E- T��t Gy 196.37C. <br /> Street Number Direction Street Name Cf Zin Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'I ExT• APN# LAND USE APPLICATION# <br /> ) <br /> PHONE#2 ExT• BOS DISTRICT. LOCATION CODE ' <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR _ <br /> qe a0VS�G770� lAlG, CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT• <br /> HOME or MAILING ADDRESS FAX# <br /> /o$ CovPoo �✓ 5�, G c )72 t^ 2-0 <br /> CITY ©GE NS STATE CA ZIP 9206+ <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 /> ^ OUNTY Ordinance Codes,Standards,ST RAL law <br /> APPLICANT'S SIGNA SD DATE: T/9 a 7- <br /> PROPERTY <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT E �'jA/jtQ,+c Tc-/- <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 /> COMMENTS: 1 IPL„_Ir+A— <br /> RECEIVED <br /> JUL 0 92002 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> c^.i�rlRnp�r,4FN??oJ NF,4ITu nlrlIpj, <br /> APPROVED BY: <br /> 'C ( EMPLOYEE#: <br /> DATE:'L r <br /> Z ? f.! <br /> ASSIGNED TO: �l- �_ EMPLOYEE#: DATE: } _G . -' <br /> Date Service Completed (if already Completed): SERVICE CODE: ( P I!E: <br /> Fee Amount: n I Amount Paid Payment Date ' <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025ERVICE REQUEST40RM <br /> REVISED 6-5-02 <br /> a <br />