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SAN JOAQIWOUNTY ENVIRONMENTAL HEALT#PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> E."�f�[y.�mow,l.�-,•1` J <br /> l '-3Qux) ('�ycj <br /> OWNER/OPERATOR n <br /> CHECK If BILLING ADDRESS�r <br /> FACILITY NAME <br /> SITE ADDRESS j } <br /> Street Number Dlreetlon Street Name _city zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) (� <br /> 4� Street Number 3k/!^ <br /> N"eTme <br /> CITY A STATE �IP <br /> NI <br /> PHONES Err. PN* LAND USE APPLICATION# <br /> PHONE 92 ExT• BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR�J� _ <br /> M- 1 � �� G�+��� CHECK If BILLING ADDRESS <br /> BUSINESS NAME J PHryONE# Exr. <br /> HOME or MAILING ADDRESS FAX# <br /> n <br /> CITY 9 STATE <br /> ZIP �1 . <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 and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FE L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR?4R7Y <br /> NACER OTHER AUTHORIZED AGENT �.� � <br /> IfAPPLICANT is not the BILLING proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 REQUESTER: 'r P <br /> COMMENTS: / '4:-C � <br /> �e <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: � �75 Amount Paid, ? /c ,-w Payment ate <br /> Payment Type t. Invoice# Check# J31 F6 Received By: <br /> v <br /> EHL]48-02-025 SR FARM Golden Rod <br /> REVISED 11/1712003 ) <br />