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NAN JOAQUIN COUNTY ENVIRONMENTALHEALTH DEPARTMENT �1 <br /> . SERVICE REQUEST • V <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0 <br /> 9� �F-06) -, Lt q, <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> /✓1 rG 01 / <br /> SITE ADDRESS a(y <br /> Street Number Dliection Street CG CiZip Code <br /> HOME or MAILING ADDRESS (If Different from SiteAddress) (� <br /> Z. rcl t ( O /( -—) TS(reeZmber Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> 610') -)a -7 J-VYI <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAmEtr PHONE# E'R. <br /> T6 & � <br /> HOME or MAILING AD/D ESS / FAX# <br /> C70�66 STATE <br /> .z <br /> / <br /> CITY STATE ZIP r •� '` <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. EDERAL laws. <br /> APPLICANT'S SIGNATURE: J DATE: ' '-O/w <br /> PROPERTY/BUSINESS OWNER❑ PE TOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is no heBILLmGPAe7•r proof of authorization to sign is required Titre <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 th-eSamdflI�Se it is <br /> provided to me or my representative. PAY�V �v'��D <br /> TYPE OF SERVICE REQUESTED: U S _6-0t7 <br /> COMMENTS: <br /> tz?— G�G"� S S'O'�-S'SAN JOAONN COUNN <br /> / HEALTH DEPARTME <br /> ACCEPTED BY: EMPLOYEE#: DATE: JQ O <br /> ASSIGNEDTO: � EMPLOYEE#: DATE: <br /> r <br /> Date Service Completed (if already completed)' SERVICE CODE: P I E: 2-3 a <br /> Fee Amount: a 7 Amount Paid a7 R c51� Payment Date /a Lf <br /> Payment Type ✓ Invoice# Check# 16t-7 Received By: -4A_ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />