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SAN JOAQL..,v COUNTY ENVIRONMENTAL HEAL?.. DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> —(/ r-t rAia SetllC-, ad 0 gS 69001,/4 6-7-� <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAMES <br /> SITE ADDRESS ^'��¢ `,IcC/ /�/�rf� + / A ,y 7av; <br /> (� Street Number Direction Street Name Cit -/ Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY /19 <br /> _ .ca/tom/p STATE ^ - ZIP G?4J` 2 f <br /> PHONE#1 rt ExT• PIN# LAND USEAPPLICATION# ✓ / <br /> ( ) <br /> PHONE#T EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAx# <br /> <2y ( 7i.-1) <br /> CITY 6 STATE (24— 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 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 PE ERAL laws. <br /> APPLICANT'S SIGNAT DATE: 12 /l/U7/ 1U l(1 <br /> PROPERTY/BUSINESS OWNER OP R ANAGER ❑ OTHER AUTHORIZED AGENT'❑ <br /> IfAPPLICANT is not the BILLIk LIARTY,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: NOVFX <br /> JoV � 62010 <br /> NFAI-TH p�P/tv���11' <br /> NT <br /> ACCEPTED BY EMPLOYEE#: DATE: <br /> 12 <br /> ASSIGNED TO: ky�6 EMPLOYEE#: 22— DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P E; 2 <br /> Fee Amount: Amount Paid 3l,�• _ I Payment Date it <br /> (lo flu <br /> Payment Type ✓ Invoice# Check# t S(o Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />