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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT '. <br /> SERVICE REQUEST x <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> vlu�il�/ CHECK If BILLING ADDRESS❑ = <br /> r[� I�� IT I <br /> FACILITY NAME <br /> SITE ADDRESS �25fl �SC•4L_yrs SGLLGTA- rl4R-+UIr]�TD� <br /> Street Number Direction Street Name cityZI Code s s i ti <br /> HOME or MAILING ADDRESS {if Different from Site Address} I Q. 017X 2—"-l ' <br /> Street Number Street Name <br /> r <br /> CIrY .=A�IM&rrb4 SrATE ICA <br /> ZIP <br /> PHONE#1 ExT. LAND USE APPLICATION# <br /> rr 4 <br /> 18-7 160 <br /> W. <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> I <br /> CONTRACTOR/ SERVICE REQUESTOR . <br /> M{ W <br /> REQUESTOR CHECK if BILLING ADDRESS ti <br /> PRONE# EXT <br /> BUSINESS NAmE <br /> HOME or MAILING ADDRESS Fax# 5 F• 0. aox 2i8_0 <br /> CITYt�y STATE ZIP i �Z ?� , a <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. ry'F yyw�> <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 F gR <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> f <br /> X. <br /> APPLICANT'S SIGNATURE: - DATE: <br /> PROPERTY t BUSINESS OWNER 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 property located at the s <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 salve time it Is x <br /> provided to me or my representative. <br /> ` VZ <br /> TYPE OF SERVICE REQUESTED: VBECEI W � _ <br /> COMMENTS: <br /> DFICSAN yoAouir COIINZ`i <br /> ENV4RONMEMM I .I. �' <br /> NEALIH t7 P7 <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> r <br /> ASSIGNED TO: EMPLOYEE DATE: <br /> Date Service Completed (If already completed): SERVICE CODE; PIE: D <br /> Fee Amount: �i Amount Paid Payment Date ` <br /> Payment Type ✓ Invoice# Check# to ` Received By: . <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />