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SAN JOAQUI OUNTY ENVIRONMENTAL HEALTEPARTMENT <br /> SERVICE REQUEST <br /> Type of B mess or ProOerty FACILITY ID# SERVICE REQUEST# <br /> { Fa- <br /> OWNER/0 ERATOR t CHECK if BILLING ADDRESS❑ <br /> n t, <br /> FACILITY NAME <br /> SITE ADDREStS <br /> 1 4're_t Number Direction Street Name Zi Code <br /> HOME Or MAILING ADDRESS I Different from Site Address) <br /> —{ Street Number Street Name <br /> CITY 1 L� STATE - �q <br /> PHONE#1 I APN# LAND USE APPLICATION# <br /> PROF EXT. BOS DISTRICT LOCATION CODE <br /> M CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR' /II I�AI CHECK If BILLING ADDRESS <br /> BUSINESS NAME- �` PH N '- )>�!XT. <br /> HOME Or MAILING ADDRESS '1�!, /' t (7N ) <br /> CITY , 1 N 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 application and that the work to be performed will be done hi accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards TATE and FEDERAL,laws., <br /> APPLICANT'S SIGNATURE: '�h ( / t V\ L W l/ DATE: <br /> ,-y h� <br /> PROPERTY/BUSL\ESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTE' <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: T h'r N`.'`:/1 ENT <br /> COMMENTS: <br /> MAY 2 6 2004 <br /> SM� •OUNTY <br /> AL <br /> k . „HENT <br /> ACCEPTED BY: �Llv t EMPLOYEE#: 0zZ DATE: 5 LwQ <br /> ASSIGNED TO: -Ti4N � EMPLOYEE#: e3 DATE: a <br /> Date Service Completed (if already completed): SERVICE CGDE: P E: 023. O Q' <br /> Fee Amount: 2-I 9 0'\) Amount Paid — Payment Date ID f G <br /> Payment Type Invoice# - Check# D a- Received By: <br /> EHD 48-02-025 <br /> SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />