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SAN JOAQUL. ,:OUNTY ENVIRONMENTAL HEALTH _„'PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or'7rope y FACILITY ID# SERVICE REQUEST# <br /> XV qq� <br /> OWNER/OPERATO <br /> 0—J CHECK If BILLING ADDRESS <br /> FACILITY NAMEAA A <br /> r <br /> SIT /�� <br /> e ID rection Street Name City ZI Code <br /> HOME or MAILING ADDRESS (If Different <br /> from Site Address) <br /> AIL-) Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 E7—7N# LAND USE APPLICATION# <br /> l ) c)q 3v�a <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONT CTOR/ ERVICE REQUESTOR <br /> REQUESTOR <br /> �ik� CHECK if BILLING ADORES <br /> BUSINESS NAME / G PH . / <br /> HOME or MAILING ADDRESS FAX# <br /> 1 <br /> CITY / STATE ZIP <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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application an he wo to eperf ed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE F Law . <br /> APPLICANT'S SIGNATURE: DATE,: / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR//MANAGER ❑ OTHER AUTHORIZED AGENT li,l <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: V iJ( bU;1J1nA Ofe twe1 <br /> 7'0 1/4t✓T <br /> COMMENTS:} /,JeLJ AS bvJd,Y Py-0P0ser'J t>1 vietft' ' df f'Y�fGG1 1/31 e5; v�l ' <br /> CAL7697 <br /> e-DV1 'fyl,+br �y}Itz jJ expose le,164 l rhe (-bsesi r0 O.Se� 6 �r FOR INSPECTION.N. <br /> P � r � i� P �7U)�/(jI! FOR INSPECTION. <br /> 24-HOUR NOTICE <br /> REQUIRED. <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> -�� lar A. 1 <br /> ASSIGNED TO: I F- EMPLOYEE#: DATE: rJ I�f <br /> Date Service Completed (if already completed): SERVICE CODE: j P i E: Lq o U U <br /> Fee Amount: fIdAmount Paid /�a Payment Date 12 2I M�N <br /> Payment Type Invoice# Check# U 4 Receive20 <br /> d By: OV�O <br /> EHD 48-02-025 SR FORM r )d) <br /> REVISED 11/17/2003 ��p, <br />