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SAN JOAQ,,- -COUNTY ENVIRONMENTAL HEALTh—JLPARTMENT <br /> SERVICE REQUEST <br /> Type of Bu ess or Property FACILITY ID# SERVICE REQUEST# <br /> ! � v ilk S2oo t '4- <br /> OWNER/GPWLA+" CHECK if If BILLING ADDRESS <br /> O v� <br /> FACUTYNAME ; ®I A ii0 4 �D�7E�-5I <br /> SITE ADDRESS L) Mfl1 N - '4 <br /> (©I Street Number Direction Street Name /J Clt Zi Coae <br /> HOME or MAILING ADDRESS (If Different from Site Address) MO�VC 7T i Q17• %� �� <br /> 1 Street Number Street Name <br /> CITY n�s STATE C A ZIP c � ?J O <br /> PIONE#1 Yc Ex . APN# LAND USE APPLICATION# 1 <br /> (SYo ) 14 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> R€QUESTOR CHECK If BILLING ADDRESS E] <br /> BUSINESS NAME <br /> 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 ENvutoNMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this to=. <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: 9 " 14 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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. L <br /> TYPEOF SERVICE REQUESTED: T <br /> COMMENTS: <br /> SEP p 3 201; <br /> HEADIN COUNT, <br /> H SPAN WNr <br /> T <br /> ACCEPTED BY: fJ4 - EMPLOYEE#: DATE: L <br /> ASSIGNED TO: eti i0e4"- c EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE RODE: P 1 E: U <br /> Fee Amount: o Amount Pai 36,(�U Payment Date ff <br /> Payment Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />