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SAN JOAQUIN %-OUNTY ENVIRONMENTAL HEALTH DL.ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S•-•to" %L� FA Cx-' 9 L 3 iZ C,(-) -) I` ''J >,- <br /> OWNER <br /> ,-OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FacalTv NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) o;2 2 j- Cg <br /> o Street Number Street Name <br /> CITY STATE nZIP <br /> GL Jr l✓Z �''� 7 Jr� R V <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> 0,vs ) .365 — 93F / — �j � bbl.-- <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> �e\ CONTRACTOR/ SERVICE REQUESTOR _ ��%� - -7-7 I Z <br /> REQUES OR <br /> CHECK If BILLING ADDRESS <br /> 142 '� <br /> BUSINESS NAME PHONE# 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNERLtf PE OR ANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is not the B/LL/NGPARTY,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. p <br /> Ri ! <br /> TYPE OF SERVICE REQUESTED: ��p �I,S ` ��' `J 1. �` <br /> COMMENTS: vG7g77W'(1 �CL <br /> rA t..oa 6.14 41V OAQUtN <br /> y <br /> EAcryO�qA M�Nry <br /> ACCEPTED BY: `' EMPLOYEE#: DATE: lL I <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �6 C P IE: <br /> Fee Amount: Amount Paid �� �v Payment Date // <br /> Payment Type Invoice# Check# !(�v Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />