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SAN JOAQL- . COUNTY ENVIRONMENTAL HEALTL ,EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> HCl <br /> OWNER/OPE TOR <br /> ��/` CHECK if BILLING ADDRESS <br /> X�y <br /> FACILITY NAMEA., <br /> SITE ADDRESS <br /> Street Number Dlrectian s mom -7JPCQde <br /> HOME Or MING ADDRESS,3 Different from Site ddress) <br /> Q /& <br /> 'a. Ll <br /> 'e 7-4J&Sk4ftW-OAa WWNumb, StreetNaine <br /> CITY STATE zip / <br /> l <br /> PHONE#1 En. APN of LAND/ISE APPLICATION# <br /> V-409) 4S7- C19/Z l L I 11 <br /> PHONE#2 Err. BOS DISTRICT LocAnCODE <br /> o <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQU,ESTOR CHECK if BILLING,-,I),,15, <br /> BUSINESS NME. / � PHONE +� ExT' <br /> HOME orIL-- ADORE X�� 441 40tAIP1 7 <br /> CITYlv L STATE, Al 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 that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL Iaws. <br /> APPLICANT'S SIGNAT DATE: <br /> PROPERTY/BUSINEss OWNER OPERATOR/MANAGER D OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> pUTHORIZATION 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. <br /> -TYPE OF-SERVICE REQUEST <br /> ED: - t-4-34 - C f=..C�-.L?;—.! -- - — ------ . ._.. ---------------- <br /> COMMENTS: <br /> G! 4- <br /> FN JUoN TMENT <br /> ACCEPTED BY: ( j L ( EMPLOYEE#: DATE: Z '- <br /> ASSIGNED TO: f4 A-� ,_? EMPLOYEE#: -` DATE: (� ! <br /> Date Service Completed (if already completed): SERVICE CODE:/ P <br /> Fee Amount �r Amount Paid Payment Date p r <br /> Payment Type lk Invoicenn# ,�,�,-� 4 Check# Received By: <br /> EHD 48-02-025 0Z k)61�-r tW D I�`� SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />