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SAN JOAQUIN ' ()UNTY ENVIRONMENTAL HEALTI- 'IEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> :E <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> /U r'1 t-) 6q I' <br /> FACILITY NAME <br /> SITE ADDRESS ,n/l a ,i �� 1 L-- -�-�,�P <br /> 5 0 Street Number DLA—) a n 1 Street Name C, C Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> (9u'T �z I - 898 I q I o-o ( P/4 --cD 3 - y� IS <br /> PHONE#2 EKT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRES <br /> BUSINESS NAME �oY t / u n — PHONE# - EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ++ti ( ) 5 a� - 90Y5l <br /> CITY STATE ZIP q5�s <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 a ordance with all SAN JOAQUIN <br /> OUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br /> IfAPPLICANT 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 <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: h as(L- One — aMeS t it /7Q <br /> 4fe-u- <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNEDT EMPLOYEE © DATE: <br /> Date Service Co peted (i already pleted): SERVICECO'DE: I PIE: ' D <br /> Fee Amount: G' Amount Paid _ Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 4&02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 - <br />