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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT DEPARTMENT <br /> SERVICE REQUEST <br /> Type of iness or Prorty FACILITY ID# SERVICE REQUEST# <br /> FA 000 7(DSP-00 4 (,:�1-7 ! O <br /> OWNER/16PERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS % / _ /7 / l �qCd P'C <br /> Street Number Direction �� reef Name Ci 'vv'/ZI-Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#tI v W Ems' APN# LAND USE APPLICATION# <br /> 4�5- <br /> PHONE#2ExT• BOS DISTRICT LOCATION CODE <br /> Oprf d�2OVI) ao 6 <br /> ONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR _ <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PH 4(.� /" (P/ 337 EXT. <br /> Y <br /> HOME or MAILING ADDRESS t FAX#g ) I U r <br /> / 2 <br /> CITY 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 apilication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, T TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: Mkul /(.C/l/ DATE: � (I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTEM <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 ate same time it is <br /> provided to me or my representative. p,YMEN <br /> TYPE OF SERVICE REQUESTED: us—T— R <br /> COMMENTS: MAT 18 <br /> SANi JO ENVIRONME M <br /> HPJ�7H DEPAR <br /> ACCEPTED BY: ',,^ -EMPLOYEE#: DATE: <br /> ASSIGNED TO: q y, ` EMPLOYEE#: - 90 DATE: <br /> Date Service Completed (if already Completed): SERVICECODE: PIE: <br /> Fee Amount: 77-1 1 Amount Paid $a D '0 Payment Date 57 r/p G <br /> Payment Type ✓ Invoice# Check# I Clp7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />