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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH llEPARTI<IIuNT <br /> SERVICE REQUEST <br /> teTFACILITY ID# SERVICE REQUEST# <br /> of Business or Property <br /> `l ' S/"' 6'70�p <br /> ?) l ✓Pi <br /> OWNER I OPERATOR CHECK if BILLING ADORFsso <br /> fACI1ITYNAME l {�✓ <br /> SITE ADD E55 `1} T ) {� ? <br /> Iku Street Number irection <br /> t l lret°t tJame � i[ d <br /> HOME or MAILING ADD SS (If Different from Site Address) <br /> Street Number _ Street Name <br /> STATE zip <br /> CITY <br /> EXT. APN# LAND USE APPLICATION# <br /> PHONE M <br /> N- all. <br /> PHONE#2T BOS DISTRICT' LOCATION CODE <br /> 1 ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> RE(�UESTO CHECK if BILLING ADDRESS <br /> MA <br /> 1 E ' <br /> EXT. <br /> BUSINESS NAME _L Vp <br /> HOME or MAILING ADDRESS { CFAx# <br /> Dr, ( 1 <br /> CITY t (1 STATE C zip <br /> BILLING ACKNQWLEDGEM[ENT: I, the undersigned property or business owner, operator or authorized agent of sante, <br /> ;ck—uoNyledge 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 forst. <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, TR and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY'I BUgNESS OWNER❑ OPERATOR/NIANAGER ❑ OTnER A omzED AGENT <br /> If.APPUCANT is not the BILLING PARTY proof of authorization to sign is require Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, L,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 /> rTyYPFOF SERVICE RELIUESTED: � R�C' ���ENTS: ' ' DE <br /> ' WROMMIENTAL <br /> IiFl+� DEPARTUFW <br /> ACCEPTE .-Y. ENIPIOYEE#: 7 DATE;! c7 / <br /> ASSIGNED TO: / EMIPLOYEE#: DATE[: !� l <br /> Date Service Completed (if already completed): SERVICE CODE, P I E: <br /> Fee Amount: tP (� Amount Paid j�j 1��� M Payment Date Z <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />