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SAN JOAQUIN` OUNTY ENVIRONMENTAL HEALTH APARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S 00 2 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME r W� <br /> SIT E ADDRESS Cl '7 Tz5r) <br /> Street Number Direction I re t Na ' 'Cly L Cotle <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number I `5—trae'ret N�a/m/e. <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# JLAND USE APPLICATION# <br /> ( 1 <br /> PHONE#2 En. OS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME ff 'G! PHONE# Em <br /> r (/( `/'1 L �i <br /> HOME or MAILING ADDRESS FAY# <br /> 7 5M)DO 01t., 1X65- 76 3 <br /> CITY L STATE ZIP -s- <br /> BILLING <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 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: /) ATE: <br /> PROPERTY/BUSINESSOWNER❑ OPERATOR/MANAGER ❑ HER AUTHORIZED AGENT <br /> If APPLlCANTisnotthe B2L/NGPARTY.proofofauthorization 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: r s PAYMENT <br /> COMMENTS: <br /> NOY 212003 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> in HEALTH DEPARTMENT <br /> ACCEPTED BY: EE#: DATE: Q <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Complet d (if already co pleted): SERVICE CODE: P 1 E: � <br /> Fee Amount: ,I O Amount Paid f�-� Payment DateVo-' eg <br /> Payment Type �/ Invoice# Check# - Received By:. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 19/17/2003 - <br />