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SAN JOAQUIr "OUNTY ENVIRONMENTAL HEALTI- EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property,,11 FACILITY ID# SERVICE REQUEST# <br /> W , ) V <br /> c I <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME , 1 <br /> SITE ADDRESS C�'l'fc� ��Z � 2 <br /> Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 6�5`Co�1 <br /> MARA Oh . Street Number Street Name <br /> CITY + STATE ZIP <br /> LENtALAK <br /> PH E#1 ExT. APN# LAND USE APPLICATION# <br /> (HE � 3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORCHECK if BILLING ADDRESS® <br /> BUSINESS NAME PHONEY —EXT, <br /> ( I 1 <br /> HOME or MAILING ADDRESS _ FAX# <br /> ( '31 — Uy <br /> CIS, nkcr)fun 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 Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: c �'m (K)rUk) DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT yJpkaNd <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 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: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(GoidEn Rod) <br /> REVISED 11/17/2003 <br />