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w <br /> SAN JOAQ COUNTY ENVIRONMENTAL HEAL? )EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> eWyw e dl( &, 9h00 -71;�g1' <br /> OWNER/OPERATOR <br /> 1 f / / CHECK If BILLING ADDRESS <br /> FACILITY NAME G <br /> SITE ADDRESS <br /> street Number I Direction I Street Name city Zip Code <br /> V <br /> HOME'or MAILING <br /> �/ADDRESS (if Different from Site Address) <br /> N• e e.. a(I S 2511 Laad 1 r 'T Street Number Street Name <br /> CITY STATE ZIP <br /> �v 60 g3�-oN <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> 411 ) "1 a�-Cl 334- <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME4A—t n' PH NE# / / fiEXT. <br /> HOME or MAILING ADDRESS FAX# (�d <br /> CITY ---Cb It 0 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 thisapplic n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: �' (G <br /> PROPERTY/BUSINESS OWN OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ I e <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/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. I f <br /> TYPE OF SERVICE REQUESTED:P,e --� 0 0 Ct. '1-tJ G�l Y`,eto i ' 'LCA.j I K I t , k ,-n6_(1:; <br /> COMMENTS: I Ytb <br /> AUG5216 <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: O r u EMPLOYEE#: DATE: V <br /> Date Service Completed (if already completed): SERVICE CODE: (�D� PVI E: 0.2, <br /> Fee Amount: ��� Amount Pa Payment Date S� <br /> Payment Type Invoice# Check# l(oZ�/ Re eived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />