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SAN JOAQUIN COUNTY ENVIRONMENTALHEALTHDEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business Property FACILITY ID# 4 SERVICE REQUEST# <br /> � s <br /> OWN RI OPERATORCHECK if BILLING ADDRESS❑ <br /> [if �l � / Z(6- <br /> FAQDTI'NAME IIL <br /> � <br /> SITE ADDRESSCC, 93a <br /> Ilrtlet KuMb� Direction„` I� 5 e Ci Zip Code <br /> HOME or MAILING ADDRESS f ifferent from Site Address) <br /> Street Number Street Name <br /> CITY (� ��� IA� ZIP <br /> PHONE#1 ExT API# LAND USE APPLICATION# <br /> ( ) $SS- C///(o <br /> PHONE#2 Ex . BOS DISTRICT LOCATION CODE <br /> CiS-y <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I I CHECKIf BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> G �P�-� � <br /> HOME Or MAILING DRESS <br /> m ) /-i�34a . <br /> CITY .C" l' E ZIP <br /> BILLING ACKNOWL DGEMENT: 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 a oc,ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, Trt1'LE and FEDERAL laws. <br /> Ir ./ <br /> APPLICANT'S SIGNATURE: DATE: 6 . <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGOROwl <br /> IfAPPLICANT 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. EN f <br /> TYPE OF SERVICE REQUESTED: R ECE M-p <br /> COMMENTS: <br /> JUN 2 6 2000 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: 2 IY-0 DATE: <br /> ASSIGNED TO: L,�S EMPLOYEE#: �-/ 3 DATE: aL <br /> Date Service Completed (if already completed): SERwcECoDE: -C P I E:'2 d OF <br /> Fee Amount: 3 I Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: _. <br /> EHD 4&02-025 .SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />