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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# <br /> SERVICE REQUEST# <br /> - <br /> (C\ f! (/ <br /> II V KJO <br /> OWNER I OPERATOR <br /> p - CHECK if BILLING ADDRESS 0 <br /> FACILITY NAME <br /> ead m <br /> SITE ADDRESS mg <br /> F <br /> Stroot Number DirectionStreet Name citv Zip Code � <br /> HOME or MAILING ADDRESS..(If Different from Site Address L/71 C' <br /> Q'ttYl l ! "� r <br /> Street Numtr <br /> ber ee ame <br /> CITY` - STATE ZIP <br /> cJ'4 tOG '�'6h <br /> ca '. <br /> PHONE#1 '� _ ExT. APN# LAND USE APPLICATION# <br /> (Ad'?) 411=~9iCIO }. <br /> PHONE#2 - ExT. - BOS DISTRICT LOCATION CODE <br /> i ? <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTIO R ,. <br /> Cind __Tv CHECK if BILLING ADDRESS <br /> _ <br /> BUSINESS NAMEPHONE# ExT, <br /> Crud Vr Ch�Idrt /V�tr� 1d DrPl 20 C, ' ng 7e,7 <br /> R HOME or MAILING ADDRESS T FAX# <br /> CITY f STATE ZIP y Jr r7 aJ <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. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR 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 pruperty located at the <br /> above site address, hereby authorize the release of-any and all results, geotechnical data and/or environmMqssessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available•ait is <br /> provided to me or my representative. �V <br /> TYPE OF SERVICE REQUESTED: P <br /> COMMENTS: <br /> C -z acr 11+` y Hp q T�RpNMCO <br /> Utq"Y <br /> DEp,AL <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: Y v • EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: `� <br /> Fee Amount: l ` r Amount Pai 1s�,tj Payment Date l v <br /> Payment Type Invoice# Check# Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> y'� <br />