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SAN JOAQU#OUNTY ENVIRONMENTAL HEALTI10PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> oo3d�7 s 6 <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> n r <br /> FACILITY NAMEfl r'l__ n /� <br /> SITE ADDRESS O� �i �l� yti�IY�f� /TIBC. pCod. <br /> Street Number Direction <br /> Street Neme Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> STATE ZIP <br /> CITY <br /> PVHONE E- APN# LAND USE APPLICATION# <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> 1 ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /' , �&s yI „ /Jar- CHECK If BILLING ADDRESS® <br /> lit/ ,Q,(�� l�, ,it��G PHONE Ezr. <br /> BUSINESS NAME 3-3000 <br /> Tic t <br /> HOME Or MAILING ADDRESS FAX# <br /> b ss los (2M) 'R5- 366 3 <br /> CITY STATE . ZIP L1626S <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 <br /> or activity will be billed to we 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 Codes,Standards ATE d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: < DATE:� k0/1,7 (0 //rr <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 13 OTHER AUTHORIZED AGENT.LY. rel r <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 t0 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: S PAYMENT <br /> VU <br /> COMMENTS: JUN 2 6 2069 <br /> SAN JOAQUIN COUN FY <br /> HEALTH DEPARTTMCNT <br /> ACCEPTED BY: <br /> EMPLOYEE M DATE. Q <br /> ASSIGNED 70: 1A I <br /> EMPLOYEE M DATE' <br /> Date Service Completed (if already completed): <br /> SERVICE CODE: P/E: <br /> Fee Amount: <br /> "� Amount Paid 3l5 O l� Paymen Date <br /> Payment Type / Invoice# Check# ��3 Received By: <br /> SR FORM(Golden Rod) <br /> EHD 48-02.025 <br /> REVISED 11/1712003 <br />