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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FA 0019 5� 1 �' <br /> WNER/OPE TOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME J <br /> SITE ADDRESS / de <br /> (j sb(�Ere'et Gumber Direction tree[Name T�� Cit • Zi CoJJ�� <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> ( ) 2321302L4 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) G(D <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> R.EQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME _ PH E# ExT <br /> -357 or MAILING ADDRESS FAX# <br /> ( I <br /> CITY STATE ZIPKe <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 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ,v1 DATES: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT I� J�,/�uy Q/'/ye-o <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 env ental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availaylsc lime time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: f5olO PICLn CA <br /> COMMENTS: <br /> New <br /> l ew tC{1.1 P1`i 14.a-1-t yN7h)OA R M�� <br /> ACCEPTED BY: C)raZ2 EMPLOYEE#: DATE: 512-9 f ' <br /> ASSIGNED TO: C EMPLOYEE#: DATE: 5 <br /> Date Service Completed (if already completed): SERVICE CODE: GJ2 3 PIE: ►�-� <br /> Fee Amount: L - LID I <br /> Amount Paid 3 ,DD Payment Date moo?LFL <br /> Payment Type Invoice# Check# Rec ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />