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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ve-Ja-il 0-and Sale6 5Ro0 -7y �19- <br /> OWNER/OPERATOR <br /> S� S an CHECK IfBILLING ADDRESS <br /> � <br /> FACILITY NAME S�Z S C.LLyl cfie5 <br /> SITE ADDRESS �/I I� 12e-41e <br /> r o / 6c i q6-2 <br /> Street Number lun K-G t�Street Name L (,� Ct % G- <br /> NOME or MAILING ADDRESS (If Different from ita Addre]�s) a1L.,n: -T )( D <br /> D E �`�(, // )O' /� rte!/` t�/f/'�Streel Numner LL Sttrre.t Na e <br /> CITY pa/ 7 i �l/L/� R-a /L�Gl co $ ZIP t- <br /> PHON�E#1 � �� APN# LAND USE APPLICATION# <br /> z` <br /> PHONE#2 SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS E] <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,STA and FEDERAL I��wtw <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OwNEmCI O RATOR/1�7ANACE OTHER AUTHORIZED AGENT❑ <br /> Jf APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE III: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 / <br />