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jJul 07 06 09: 44a Jeffrey C. Henley 714-7''9- 1499 p, 7 <br /> SAN JOAQUTA COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> re�'----,�-na., 003 1 y ggDc 4 -� 3 3 �- <br /> OWNER/OPERATOR <br /> I��Q CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Z S-rr S. <br /> 1 SStreet Number I Direction Slreac Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN* LAND USE APPLICATION$ <br /> PHONE#2 Ex7. BOS DISTRICT LOCATION CODE <br /> { ) <br /> CONTRACTOR /SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if 81LUNG ADDRESS <br /> BUSINESS NAME �A PHONE# ExT• <br /> HOME or MAILING ADDRESS FAx# <br /> ( (o) ('� <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 EWARONMENTAL 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 /> 1 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 FE laws. <br /> APPLICANT'S SIGNATURE: DATE.:/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MAYAGFR ❑ OTHER AUTHORIZED AGENT E3 PCCs Cr <br /> If APPLICANT is not the BILLING PART}',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 environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAI,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: vl <br /> COMMENTS: <br /> . r <br /> sgNJo 01006 <br /> h ,'-Alt/, UiN co <br /> FACry�PgRT�UNry <br /> �j <br /> ACCEPTED BY: �, Y .�` EMPLOYEE#: I.//,/ C DATE: /7L <br /> / <br /> ASSIGNED TO: C ; ` I EMPLOYEE#: �) 7 .� DATE: / X <br /> Date Service Completed (if already comp) d): SeRmcr Conr: C,- <br /> C( P I E: <br /> Fee Amount: 7 Amount Paid Payment Date t J <br /> Payment TypeInvoice# Check# Received <br /> n` <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 Y-1 <br /> ENVIRONMEN'i HEALTH <br /> PERMIT/SERVICES <br />