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SAN JOAQUJ-' COUNTY ENVIRONMENTAL HEALTTT DEPARTMENT <br /> ' SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ySERVICE REQUEST If <br /> OWNER/OPERATOR rJ � P <br /> !C � f1�C%J�—� ��� CHECK If BILLING ADDRES <br /> FACILITY NAME <br /> SITE ADDRESS `— r� /c \ G(TF �_ <br /> Street Number Direction Street Name CityrZip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <� <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ` EXT. APN# LAND USE APPLICATION If <br /> [PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CIN 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 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 11 ti n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE d FEDERAL laws. <br /> _ r� <br /> APPLICANT'S SIGNATURE: DATE: h I� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 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. <br /> TYPE OF SERVICE REQUESTED: IGt T EN7 <br /> COMMENTS: RECEN <br /> W.G % 2005 <br /> SAN 30P'QuIN CW4"N <br /> ENVIRO�PAR MEW <br /> LTH� <br /> ACCEPTED BY: ��L L I Gam' EMPLOYEE �', 7�I DATE: �US <br /> ASSIGNED TO: ti EMPLOYEE#: C,- 5.3 DATE: <br /> Date Service Completed (if already completed): ('� SERVICE CODE: P 1 E: <br /> Fee Amount:- - ? G,( t Amount Paid — Payment Date <br /> Payment Type Invoice# Check If Io2 } ecetved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />