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i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> i <br /> SERVICE REQUEST i <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> o'er , mar �>( ) e �e' <br /> OWNER/OPERATOR <br /> A7l D CHECK If BILLING ADDRESS <br /> FACILITY NAME `L <br /> IfNaA <br /> SITE ADD RFsc 6, T <br /> S� <br /> -799 ) Street Number Direction /'! Street Name Clt ZI Code <br /> HaME or MAILING ADDRESS (If Different from Site Address) <br /> 't Street Number Sheet Name <br /> CI Y % CCLSTATE ZIP q. S-q <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# j <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> s <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> J <br /> REQUESTOR !1 � �1 U u CHECK if BILLING ADDRESS i <br /> Vt \ 1 <br /> BUSINESS NAME Vl PHONE _/ EXT. <br /> HOME or MAILING ADDRESS � ��r� S FAX# <br /> CITY rlI f i (,IX! STATE CYJ`u ZIP C/ {� <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 laws. t / I <br /> APPLICANT'S SIGNATURE: /� p <br /> lit !�yc�(/ DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER Lp OTHER AUTHORIZED AGENT❑ <br /> If,IPPLICANT is not the BILLING PARTY 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/sit e'Cssssmmentti <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the S3c ''`•• <br /> provided to me or my representative. C T <br /> IV <br /> I <br /> TYPE OF SERVICE REQUESTED: 1 <br /> COMMENTS: SANJOFN 204 QUI ! ; <br /> Vj N <br /> pP� O�UN <br /> N <br /> ACCEPTED BY: e EMPLOYEE#: DATE: 1 <br /> ASSIGNED TO: .� ( EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: PIE: <br /> Fee Amount: 5 Amount Pai �5 a b Payment Date <br /> Payment Type ld� Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />