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` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> I -F q0 q/ <br /> Type of Business or Property a "" FACILITY 1D# `'' SERVICE REQUEST# <br /> r..Sf <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> _] <br /> FACILITY NAME <br /> SITE ADp *-r <br /> ff 'a a& Street Number Direction Street Name city Zle Code <br /> HOM�Efor/M/AILING ADDRESS (If Different from Site Address) <br /> '7'U ��� 'li9/� 44V o�J- Street Number Street Name <br /> CITYSTATE ZIP <br /> � <br /> PHONE#'I ExT• APN# LAND USE APPLICATION# <br /> f ) .2Z 2 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> I CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS E] <br /> i BusiNess f <br /> AME PHONE# T' <br /> HOME or MAILING ADDRESS FAX# <br /> v� ( ) `f �f <br /> —CI TY 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 /> I activity will be billed to me or my business as identified on this forth. <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 DERAL laws. <br /> APPLICANT'S SIGNATURE: �� l DATE:OF <br /> PROPERTY/BUSINESS OWNER RA R/MANAGER Ek-� OTHER AUTHORIZED AGENT <br /> If,4PPLICANT is not the BILLING PART'proof of authorization to sign is required �D1{ME FF <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the pr4V6,-UYt09t the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site as5��t51&1�ent <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and go*sail Cu15e'lt is <br /> provided to me or-my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> t i✓> � GO N -c-t�T�-i'z�'"t' ' ENVIRONPARTiNEM <br /> COMMENTS::.y <br /> ACCEPTED BY: EMPLOYEE#: � DATE: <br /> ASSIGNED TO: u EMPLOYEE#: DATE: Ids— <br /> Date Service Completed (if already completed): SERVICE CODE: Q P/'E: �C-�, p2_ <br /> Fee Amount: Amount Paid 1 $� oci Payment Date \\4\ a S <br /> Payment Type �� Invoice# Check# \`O Z Received By: N <br /> EHD 48-02-025 SR FbI M"(Golden`Rod} <br /> REVISED 11/17/2003 <br /> F <br />