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SAN JOAQU :OUNTY ENVIRONMENTAL HEALTI ZPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST P <br /> Ctrs STS i colo <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME �&—\-e-LL)aqK u <br /> SITE ADDRESS <br /> Sutre�eit-Number DireWction L TStreet Name 1 Cit Zi Codeb <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 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILUNG.ADDRESS <br /> BUSINESS NAME - PHONE# EXT. <br /> Lac,. ( LIDS) a(3- 03 8 <br /> HOME or MAILING AD gR S FAX# <br /> CITY S�A �� STATE 04 <br /> ZIP ?T1 <br /> sl �•� <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 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 /> COUNT), Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: jj,( tr,'Gwr 1,' .Gy �'�i.ut � DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHERAtITNORizEDAGENTRQ�0ELxVLp6:LL1:' 04iller <br /> 11'r1PPLIC'ANT is not the BILLING PARTY,proof of authorization to sign is required Tule <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. �l <br /> TYPE OF SERVICE REQUESTED: S`� !Ii5C6 L1 <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <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 11/17/2003 <br />