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• SAN JOAQUIN rOUNT INVIRONMENTAL HEALT' IEPAR--TENT <br /> SVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Sit <br /> 00 30451 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> n SUSah 'V <br /> FACILITY NAME <br /> SITE ADDRESS pp <br /> .0 Street Number Direction Street Name Ci Zin Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number T Street Name <br /> CITY STATE ZIP <br /> PHONE#1 E)cT• APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Ill PHONE# ExT• <br /> .s <br /> HOME or MAILING ADDRESS 4. FAX# <br /> CITY �� STATE r /�_ 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 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: LCL s� tiz�� DATE: �// <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER ❑ OTHER AUTHORIZEDAGENTTR' r—I\"I1 IELgf iy1't-rr <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: SOI S I�aY! 1 S 11 <br /> COMMENTS: 2 � PAYMENT <br /> RECEIVED <br /> c° JUL I 12002 <br /> PAN JOAQUIN COUNTY <br /> UBLICHEALTH SEa'JICES <br /> ENVIRONMENIRAL HE-" <br /> APPROVED BY: EMPLOYEE#: 2 Z "L DATE: <br /> ASSIGNED TO: EMPLOYEE#: O ( DATE: ", . �1 — �• <br /> Date Service Completed (if already completed): SERVICE CODE: ZZ P I E: Z(p <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# FE heck# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />