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ti <br /> ' SAN JOAQUINf&-DUNTY ENVIRONMENTAL HEALTFEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACIILITY ID# SERVICE REQUEST# <br /> _F--� V (:� <br /> OWNER t OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Str et Name City Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APIN# LAND USE APPLICATION# <br /> (20cl) c!-_�) 1 - y 600 <br /> PHONE 1#2 EXT. SOS DISTRICT LOCATION CODE <br /> i 1 <br /> CONTRACTOR p SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> C V�� r cLe+'-o C` <br /> HOME or MAILING ADDRESS FAx# _ <br /> aec <br /> CITY ` QC� STATE ctrl 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 in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Cortes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: N ` DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT [L�� � <br /> If APPLICANT no the BLLLIN_ __ G�proof of authorization to sign is required Title <br /> AUTHORIZATION TO RE ASE 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. L4q - <br /> TYPE OF SERVICE REQUESTED: <br /> fiDh1MENT5: <br /> N 4 2004 <br /> SAN JOAQUIN C <br /> ENv <br /> Hca rr���Pa�M�� <br /> ACCEPTED BY: EMPLOYEE#: G DATE: <br /> ASSIGNED TO: 1 ww I/ EMPLOYEE�: � �"2, DATE: L� 1�/ � q <br /> Date Service Compl ed (if already completed): SERVICE CODE: P I E: 3 C/ <br /> Fee117 <br /> Amount: Amount Paid Payrrlent Date a <br /> Payment Type Invoice# Check# J Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />