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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# / SERVICE REQUEST# <br /> FIT0 //� SC- 661�// 0 <br /> OWNER/OP TOR <br /> Q t7 CHECK If BILLING ADDRESS O <br /> FACILITY NAME <br /> SITE ADDRESS <br /> �/J/� �// <br /> Street Number Direction /�` D1:9-X r�e'E Nam �" Cit Zi Code <br /> HOME or MAILINGADDRESS (If Different from Site Address) <br /> �LG`21 Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (av9) ? !r- 1.3110 <br /> PHONE#"L ExT• BOS DISTRICT LOCATIOODE <br /> ( ) 06 � <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS, <br /> BUSINESS NAME PHONE /J_ G/_� p EXT. <br /> Q CF J <br /> HOME or MAILING ADDRESS FAX# <br /> Ila- <br /> CITY [ L � -� 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 /> v� <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> /fAPPLICANT 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 environmentP,ittteeee assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and �%p <br /> it is <br /> provided to me or my representative. fto c <br /> TYPE OF SERVICE REQUESTED: � SU FP 9 ,7 <br /> COMMENTS: ✓QqQ 19 <br /> ( ,nckfjge c3�C ocone-,- co <br /> ACCEPTED <br /> n- <br /> RTMFNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 9 <br /> ASSIGNED TO: / EMPLOYEE#: DATE: 0)- 3— <br /> Date <br /> )< J—Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> (e U Z <br /> Fee Amount: Amount Paid Payment Date / <br /> Payment Type Invoice# Check# 1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />