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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 3 Wy69� <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS /�,/T �//7J` q - <br /> Street Number Direction Strc Name fad (,V�'' �Zt C 80all \ <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> street Number L Street Name <br /> CITY - STATE ZIP <br /> PHONE#t EXT. APN LAND USE APPLICATION# <br /> 4 L56 <br /> PHONE92 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR It SERVICE REQUESTOR ggg <br /> REQUESTOR <br /> �r /l CHECK If BILLING ADDRESS <br /> BUSINESS NAME o7 f0 Sa PHONE# EXT• <br /> HOME Or ILIN AD RESS FA%# <br /> Cl 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 projector <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,ST a FEDEpAL la�� <br /> APPLICANT'S SIGNATURE: �1y�t DATe: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> 1jAPPL/GNT is not the BILLING PARTY proof of authorization to sign is required Titre <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, MEP I <br /> TYPE OF SERVICE REQUESTED: RECEivED <br /> COMMENTS: jUN 18 2004_ <br /> r L SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY[ - EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I P 1 E: (7i <br /> Fee AmoVnt: Amount Paid Payment Date \� <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> OC\/ICCl��rl�'IYthh'a <br />