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SAN JOAQUII�COUNTY ENVIRONMENTAL HEALTHIPEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR n/ <br /> CHECK If BILLING ADDRESS O <br /> FACILITY NAME I <br /> SITE ADDRESS Jri/p <br /> Street Number Direction Str et Name Cwt 2i Code <br /> HOME or MAILI umber G ADDRESS f Different om Site Address) <br /> 36/" � Street NStreet Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION��� <br /> Zig <br /> PHONE#2 Er. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR // <br /> ///0/tf CHECK If BILLING ADDRES <br /> Ja <br /> BUSINESS NAME <br /> Exr. <br /> HOME Or MAILING ADDRESS FAX <br /> CITY ' STATE <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 aj3d that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STfkTE and EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER 10 OP OR/MANAGER 11 OTHER AUTHORIZED AGENTir <br /> If APPLICANT is not the INGPARTY 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/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: /2-/-7((6- <br /> JAL —'req C f- xwlieq <br /> lor� c,&5 d UIN GOON <br /> o <br /> // N- <br /> /g..r.:�J ( 51 r/r/;e) v"` r� SAN JOP O MEt�M CIT <br /> NO\.\VIE P E <br /> ACCEPTED BY: /�/ / EMPLOYEE#: 10 / DATE: <br /> ASSIGNEDTO: E EMPLOYEE#: 396 DATE:/'/Y'615 <br /> Date Service Completed (if already completed): T SERVICE CODE: P 1 E: <br /> Fee Amount: Amount Paid Payment Date CIS <br /> Payment Type Invoice# Check# 3C:lx Receive By: N <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />