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SANJOAQUIN UOUNTY ENVIRUNYILiNIAL naAr rn <br /> SERVICE REQUEST <br /> Type of Business or Property L FACILITY ID# SERVICE REQUEST# <br /> Co e2 Cur{ ti(p�cZe �� Of Una 1 S(tioD 4 9 �4 3� <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> O <br /> Street emb r Direction / vV Street Name cm Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Sheet Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( ) //3 / F00 '7 <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /' ` CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# ' <br /> 7-2- 0 < _Vo-o' 0 <br /> HOME Or MAILING ADDRESS FAX# <br /> CIN s r,, STATE ZIP 1, <br /> l <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 projector <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 work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST and FEDERAL 1 s. / <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/M AGER ❑ OTHER AUTHORIZED ACENT❑ <br /> Jf APPL1cAN'T 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. <br /> TYPE OF SERVICE REQUESTED: ECEI V ED <br /> COMMENTS: 6 JAN 1 M7 <br /> O <br /> SANN <br /> VRONMEN COUNTY <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: L(G 7 DATE: (_ _() <br /> ASSIGNEDTO: EMPLOYEE#: V ( (f DATE: _( T —0 7 Service Completed (if already completed): SERVICE CODE: 5 2 Z PIE: I" [ <br /> Fee Amount: O _ &C Amount Paid Payment Date <br /> Payment Type eti Invoice# Check# Received By: <br /> EHD 48-02-025 ' .SR FOR.M(Golden Rod) <br /> REVISED 11/17/2003 <br />