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r <br /> SAN JOAQUI,.,OUNTY ENVIRONMENTAL HEALTI,.OEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# nSEERVVIICE REQUEST# <br /> -T a '3 F—o L1 �S <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS <br /> FACILITY NAME t -Fn 4 <br /> SITE ADDRESS 5<2-Df p wpo� <br /> street Number Direction reef Name J� J Cit <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number §treet Name <br /> CITY STATE ZIP <br /> PHONE#t ExT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS El <br /> BUSINESS NAME PHONE# / `��Ex <br /> ZA2cei- n�:))� (;�M <br /> HOME or MAILING ADDRE SFAx# <br /> I Ll <br /> ( ) <br /> CITY EAnc IL 2 STATE 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,Standards,STATE and FERE L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER© Po­,/MANAGER 0 OTHER AUTHORIZED AGENAEr <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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: 10 t44L RECEIVED <br /> COMMENTS: t 20 <br /> .fUN - 1 U L <br /> SAN.}OAQUIH COUNT" <br /> E?MR0NbIEN7AL <br /> HEALTH DEaARrUEN <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> A <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if 1.already completed): SERVICE CODE: PIE: <br /> PIE: <br /> Fee Amount: "-31S Amount Paid co' <br /> 3 7-1�) Payment Date h [ L <br /> Payment TypeInvoice# Check# . 4 ( r ReceivedBy: -4-1't <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />