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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> S`ERVI'CE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME Le <br /> SITE ADDRESS <br /> Cn <br /> / (/�{ <br /> Street tuber Direction Y Y O Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. PN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRA RVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> L�✓ <br /> BUSINESS NAME PHONE# ExT. <br /> !Zt tI� ( Z43 tr' <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> Qt4- LA <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 or <br /> 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,Sta a s,STATE and FEDERAL laws. JJ <br /> APPLICANT'S SIGNAT `r DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT LQ IAC JGvy\C,,� <br /> If APPLICANT is n t the BILLiNGPARTY,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. <br /> TYPE OF SERVICE REQUESTED: \YN i E N1 <br /> r - <br /> COMMENTS: <br /> �E JUN 12 21306 <br /> SAN JOE',QU111;COUNTY <br /> r ENVIRONME14TAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: C EMPLOYEE#: 67 5 3 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: (�. J Amount Paid 5 Payment Date I 1(1 <br /> Payment Type Invoice# Check# 3 (1 Received By: <br /> EHD 48-02-025 ���� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> (X` <br />