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SAN JOAQUII OUNTY ENVIRONMENTAL HEALTH TIEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C„r <br /> OWNER OPERATOR <br /> CHECK If BILLING AODRESS� <br /> FACILITY NAME <br /> SITE ADDRESS ���L <br /> I Street Number DKireJction 1J Street Name CIl to <br /> Ln 1 Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> — street Number �l reel Name <br /> CITY �rtec1c STATE ZIP <br /> PHONE#I EXT. APN# LAND USE APPLICATION# <br /> rZ`J9) 93 --7591 tL-1S'- Z-)o - dq <br /> PHONE#2 EXT BOS DISTRICT LOCATION CODE <br /> ( I 1 <br /> CONTRACTOR/SERVICE REQUESTOR SCo PwkZADDRESS <br /> REQUESTOR p'^`I'.VCHECK((BUSINESS NAME,/ , ( PHONE# 5 7 HOME Or MAILINy RE S� OFAx <br /> 2 OO ( 1 V <br /> CITY �. c _ ` L „C6v, STATE G zip <br /> BILLING ACKNOWLEDGEMENT: 1, 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 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 Codes,Standa STATE trd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> DATE: 'G A.4 o n <br /> J-K- --� <br /> PROPERTY/BUSINESS OWNER❑ ,RA /NIANAGER1 OTHER AUTHORIZED AGENT <br /> /1APPLICANT is not the ILLING 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: I <br /> COMMENTS: RECEIVE <br /> JMo92 <br /> JOAOU1N OOl1N <br /> N H DEPAA; aU <br /> ACCEPTED BY: EMPLOYEE#: t' / DATE: hq <br /> ASSIGNED TO: EMPLOYEE#: ` 1• DATE: V <br /> Date Service Completed (if already Completed): SERVICE CODE: / <br /> E7'36"1 <br /> Fee Amount: Amount Paid Payinent Date <br /> apaDU mQJO <br /> Payment Type V,� Invoice# Check# g g Received By: <br /> EHD 4ED 11/1 SR FORM(Golden Rod <br /> REVISED 11/17/2003 <br />