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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR � ^V� <br /> V 1 D CHECK If BILLING ADDRESS . <br /> FACILITY NAME <br /> SITE ADDRESS �Y ." <br /> Street Number Direction Street Name Z Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY � �V—+ STATE CA— ZIP ci4sxc — <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICTUw 7 LOCATION CO E <br /> ( ) 0 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> V1 G,L � CHECK If BILLING ADDRESS <br /> BUSINESS NAME (' PHg-ccl � EXT. <br /> �(1 ONE# <br /> HOME or MAILING ADDRESS � FAx# <br /> �io2 Cts �vtC�h P..� I S'tDc�`h r ( ► <br /> CITY STATE CSA, ZIP q� <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 t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: �(L-zi�,iq <br /> PROPERTY/BUSINESS OWNERS ERATOR/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 andilame time it is <br /> provided to me or my representative. �Iyt ' <br /> TYPE OF SERVICE REQUESTED: fes'J C 51.L1-� l <br /> COMMENTS: 6 <br /> coctvtcy 0� SAN j0AQU/'V CO <br /> 2Qif9 <br /> HEAL-r, EPgR /- <br /> ACCEPTED BY: - (D eO-vi l J EMPLOYEE M DATE: <br /> ASSIGNED TO: C7 � t� EMPLOYEE M DATE: 1 <br /> Date Service Completed (if already completed): SERVICE CODE: D(o l P 1 E: <br /> Fee Amount: S Z Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: � <br /> { <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />