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SAN JoAQ[JIN COUNTY ENVIRON1VtENTAL U�EALTI3 B <br /> {, <br /> SERVICE REQUEST <br /> type of Business or Property FACILITY ID# SERIIlCE RE <br /> OWNER I OPERATOR � � O. CHECK i I <br /> rFACIOTY NAME <br /> SfTEA®oREssf��7 j <br /> iSfr/`e umber Dlreatlon 5 eat Na a 7J Code <br /> HQME Or MAILING ADDRESS (if Different from Site Address) <br /> [reetNumber S etNas <br /> CITY STATE ZIP <br /> PHONE V EXT- APN# LAND USE APPLICATION# <br /> ( Z S--U1— <br /> PHONE#2 EX-T. BOS DISTPJCT LOCATION CODE m <br /> CONTRACTOR/ SERVICE REQLTE'STOR <br /> REQUESTOREl <br /> CHECK If BILI;ING ADDRER�,4 <br /> r <br /> BUSINESS N E ' PHONE# � ' <br /> HOME or MAILING ADDRESS / FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acimowledge that all site and/or project specific ENVMONMENTAI_IJEALI'H DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as ' entified on this form <br /> I also certify that I have prepared this app 'on and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards and FEDERA ws. <br /> APPLICANT'S SIGNATURE:4 <br /> i <br /> PROPERTY/BUSINESS OWN FR PE.RAT0R/iV1ANAGER ❑ OTHERAUTH(?RfzEDAC-ENT <br /> ❑ <br /> If APPLICANT is not the BILuNG,PARTY,proof of authorization to sign is required TWe <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize tb,; release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUTN 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 4F SERVICE REQUESTED: J �,�y •, . EG�G�� <br /> COMMENTS' <br /> SAS� OO�OE S <br /> ACCEPTED BY: EMPLOYEE I : DATE: <br /> �f i C <br /> ASSIGNED To. b EMPLOYEE J : DATE; <br /> Date Service Completed (if alrsady comp)eted): SERVICE CODE: PIE:42 Qy <br /> Fee amount: 11r Amount Paid OA� � Payment fate W `p g <br /> Payment Type l� Invoice# Check# p� l�'L Received By: <br /> EHO 48.02-025 tjj j j <br /> REVISED 11117!2003 <br />