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SAN JOAQUV- —9UNTY ENVIRONMENTAL HEALTI-T ')EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> I'l7 Nt c�7 <br /> OWNER i OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS �� 1 <br /> Stre'eumber Direction lr Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 5xiStreet Number Street Name <br /> STATE�� _ ZIP C C��',, <br /> CITY � � C 1 � — <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (51 )0 t-7.5 v 3 q <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME `\^//{,��/7-CJ �1) P NE# /^�/l <br /> EXT. <br /> L 4 '4�' Y V V ( •) v C3 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY ( t STATE ZIP <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 CodesoStandai ATE and FE ERAL laws.APPLICANT'S SIGNATkw <br /> DATE:PROPERTY/BUSINESS OWNSRATOR/ )ANAR ❑ OTHER AUTHORIZED AGENTIfAPPLICAEING PARof of authorization to sign is required Tirte <br /> AUTHORIZATION TO RELEASE INFORMAWhen 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 a�4 at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: TAT ( L ( ("L- �' (I;C-(C— FJ I/P <br /> COMMENTS: SAN 312 <br /> FN/1 008 <br /> H Ttio p� ;'Ulvry <br /> NT <br /> ACCEPTED BY: L k% EMPLOYEE#: �i ?j Z j DATE: <br /> ASSIGNED TO: EMPLOYEE#: (Lt DATE: _ 3 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: ? Amount Paid 3 i Gj O Payment Date (� '31 )D� <br /> Payment Type �' Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />