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SAN JOAQUIl` )LINTY ENVIRONMENTAL HEALTARTMENT <br /> SERVICE REQUEST EP <br /> Type o usiness or Property FACILITY ID# SERVICE REQUEST# <br /> 'TWD din fA C mc-7-->6 C <br /> 0WNEf2/,qPE TOR <br /> CHECK If BILLING ADDRESS El <br /> FACILITY NAMrt <br /> S 1 TE ADDRESS Street Number 4 ietction �t�eV' am6 6ityZi Code <br /> HOME Or MAILIN DDRE S (If Different fr•yo'�,�Site r(ess) <br /> � LIJ� V• Street Number Street Name <br /> CITY PV111UU (01;ATE ZIP <br /> PTE�1 EXT• APN# LAND USE APPLICATION# <br /> PHONE#2EXT• BOS DISTRICT LOCATION CODE <br /> ( 1 -7-7 - 0 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUEST It <br /> f AIL <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHO # EXT. <br /> HOME or MAILING ADDRESS <br /> CITY , STATE - I <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 appIt i nd that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST E'and�FDERAL s. <br /> APPLICANT'S SIGNATURE: rt /�c.� '� (�/GC/l0 DATE: �J�� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ rA , <br /> If APPL/CANT 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: U57 PAYMPNIT <br /> 41 <br /> COMMENTS: RECEIVED <br /> JAN 2 0 2004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPAPITMEND <br /> ACCEPTED BY: EMPLOYEE#: q&qq DATE: 2 <br /> ASSIGNED TO: �y d EMPLOYEE#: 7 3 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: f PIE: <br /> Fee Amount: Amount Paid Payment Date j, kp D <br /> Payment Type Invoice# Check# �D� Received By: <br /> EHD 48-02-025 SR FORM(Golden <br /> REVISED 11/17/2003 VNN� <br />