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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Typeusiness or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR , CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS ?/��(// J /S ��/1e(~l�.%•-�(.5 � �.Sa �v <br /> Street Number Direction treat Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) Zr1/5 N Cly J ►/I t <br /> ! Street Number Street Name <br /> CITY r �� ), STATE � ZIP <br /> PHONE#1 I� EXT- APN# LAND USE APPLICATION# <br /> -7-7 (Z o-,3\ac \gyp <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) 0c`A 1 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> v <br /> BUSINESS NAME PHONE# 3� -77-/ <br /> EXT,�' ' <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 <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,STAV PrO FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: /'�Z' <br /> PROPERTY/BUSINESS OWNERR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 environmental/ it as ssment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> 4 rH'y,0Sj�C0 <br /> M NT <br /> ACCEPTED BY: C 6 EMPLOYEE#: DATE: <br /> i <br /> ASSIGNED TO: W- ��Z EMPLOYEE#: DATE: A M <br /> Date Service Completed (if already completed): SERVICE CODE: 513 P i E: <br /> Fee Amount: Ltzs-(o_01 Amount Paidp tL"C–y,d-6Payment Date[—U <br /> �� <br /> Payment Type Vis„ Invoice# C ck#6X- � Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> ep,gN4 <br />