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SAN JOAQUIN COUNTY ENN'IRON-VIENTAL HEALTH DE'PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> I OWNER I OPERATOR <br /> CHECK if BILLING ADDRESS <br /> r FACILITY NAME <br /> r " <br /> SITE ADDRESS I <br /> �- is <br /> E �ill�Street Number Direction Street Name it Zip Code <br /> a <br /> HOMEVI—MAILING ADDRESS (If Different from Site Address) <br /> iteAddress) <br /> Street Number Street Name <br /> CIN L STATE ZIP <br /> CA <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> f 1 <br /> t CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORyam{ <br /> i K � _ CHECK if 63LLING ADDRESS <br /> li TT�� ``'� 1�L' / ` <br /> BUSINESS NAME } t, PHONE# EXT. <br /> cigF -17�L1 <br /> HomE-crMAILING ADDRESS FAx# <br /> Ic Te (2C,r. ) Ci'qF-et_-2 { <br /> CITY �3 �� STATE c 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 HEALTE-I 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 certiry that l have prepared this application and that the nvork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL la"s. <br /> APPLICANT'S SIGNATURE: Z1 DATE: C,�f S' � <br /> PROPERTY/BUSINESS OWNER ElOPERATOR I MANAGER © OTIIER AUTIIOltizED AGENT - .•ltd:�E,�'� �� <br /> If APPLICANT is not the BII_LIrVG 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: v= <br /> � �� 2 Com- <br /> �� JUN 1 3 2005 l <br /> SAN JOAQUIN COUNTY <br /> y <br /> ENVIRONM>=NTAL f ,J <br /> ACCEPTED BY: EMPLOYEE M TE: G <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICEDE: PIE: <br /> G <br /> Fee Amount: Amount Paid /yment Date <br /> Payment Type ✓ Invoice# Check#1 ^ Received B <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> I'� REVISED 11/1712003 <br />