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SAN JOAQU. 20UNTY ENVIRONMENTAL HEALTL EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SEER�VIfCCE1 REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME-7_L�/l r���e� 1l7 1 <br /> SITEA7QPR,(ESS vtcc y" <br /> Street Number Direction G Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR- <br /> CHECK If BILLING ADDRESS <br /> \t� qS e— C�e Lk ss I—�'jZ—�Zg7 <br /> BUSINESS NAME PHONE# EXT. <br /> I-C Serv•ceS GTq �t�4 X73b <br /> HOME or MAILING ADDRESS FAX# <br /> Or ( ) �tti�{-1735' <br /> CITY • --7v-e rp o STATE nZIP ' 3�2 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 1 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: 0001, D:tTE: <br /> PROPERTY/B11SINESSOWNER❑ OPERATOR/MANAGER ❑ OTHER AU"r110RIZEDAGENT JX <br /> IrAPPLlC,INT is not the BILLING PARTY,proof of authorization to sigh 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 DEPARTMFN'I'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: V V P,qy m C O <br /> COMMENTS: CE/`/ -3 <br /> OC � � IV <br /> S <br /> %�o m= N <br /> HEAR h 2 2�„ Cn v <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I Ct O PIE: Og <br /> Fee Amount: Amount Paid Payment Date /p <br /> Payment Type Invoice# Check# � Received By: <br /> \(D/ <br /> EHD 48-02-025 O v r (ttgfl VI Il "t �,'1U SR FORM(Golden Rod) <br /> REVISED 11/17/2003 JJ <br />