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SAN JOAQUIN � OUNTY ENVIRONMENTAL HEALTV T)EPARTMENT <br /> SERVICE REQUEST .� <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property r <br /> 3 Z 3 2 i vs <br /> OWNER I OPERATOR " CHECK if BILLING ADDRESS <br /> L -�F N l-I <br /> FACILITY NAME C <br /> SITE ADDRESS /' <br /> 4 Street Name Ci ZI Code <br /> Street Number Direction <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> STATE ZIP <br /> CITY �4eR L LA 9S 7 7 <br /> PHONE#1 Exr_ APN# LAND USE APPLICATION# <br /> 232 -?,40 -fib <br /> PHONE#2 Ex . BOS DISTRICT LOCATION CODE <br /> 3 <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> PHONE# ExT. <br /> BUSINESS NAME ( ) <br /> HOME or MAILING ADDRESS Fax# <br /> CITY STATE ZIP <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 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 application and that the Trk fo be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDEM12WS. <br /> APPLICANT'S SIGNATURE: Lf DATE: O <br /> PROPERTY/BUSINESS OWNERF-t OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILGING 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: et'tvS I.LL'r'q- D NJ — /\J rP—L / OZ/J /`�>=s� PAYMENT <br /> COMMENTS: JAN 13 <br /> 2M <br /> SAN JOAQUIN COUNTY <br /> IARONIVIENTAL <br /> HEALTHEPARTMENT <br /> ACCEPTED BY: C-I L 4 t "--r T EMPLOYEE M m 3 Z DATE: (3 <br /> ASSIGNED TO: �� EMPLOYEEM r �"ne DATE: 3 O <br /> Date Service Completed (if already completed): . SERVICE CODE: P E p Z— <br /> Fee Amount: - C Amount Paid i C�,✓ -� Payment Date [ 13 to 9 / <br /> Payment Type -S t- Invoice# Check# Received By: ,C <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />