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SAN JOAk, N COUNTY ENVIRONMENTAL HEAL DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or <br /> Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS ��Jyy Q� Al <br /> t� StreetlN�umber Direction F/ Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 113�(/ 1//✓c T � <br /> Street Number Street Name <br /> CITY /1. _ .caZc-`J m n STATE ^ - ZIP G?4J`� r <br /> PHONE#1 Ex7 APN# LAND USEAPPLICATION# ✓ / <br /> ( ) <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR / CHECK If BILLING ADDRESS <br /> _ <br /> F ;�Ic, I/4k�,G, r <br /> BUSINESS NAME/ PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE r) n_ ZIP <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 /> I also certify that 1 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 E ERAL laws. <br /> APPLICANT'S SIGNAT DATE: /2 Al16v1Q to <br /> PROPERTI'/BUSINESS OWNER OP R ANAGER ❑ OTHER At!THORIZED AGENT❑ <br /> JfAPPL/CANT is not the BILLI ' ART),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: AYM <br /> COMMENTS: NO <br /> I/'© <br /> 1620/q0 <br /> Hby 'RQU/N O <br /> ou <br /> ��RD <br /> ACCEPTED BY EMPLOYEE#: DATE: <br /> ASSIGNED TO: Art-;6 <br /> CAX-rR EMPLOYEE#: j Z DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE: Z <br /> 399 <br /> Fee Amount: Amount Paid 3� Payment Date 1 I 1 <br /> Payment Type ✓ Invoice# Check# 14 9 S L,-7Received By: US <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />