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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> .S2 dO�G/33 <br /> OWNER/OPERATOR o <br /> J �'N' /� <br /> / ��//l�� CHECK if BILLING ADDRESS <br /> FACILITY NAME I G/ I <br /> SITE ADDRESS� .lm N. Ac SNL A�/G O <br /> Street Number Dimetion S[reet Name (/l CI i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ec . APN I LAND USE APPLICATION# <br /> PHONE#2 Ez. BOS DISTRICT LOCATION CODE <br /> ( ) 711 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / ��Z <br /> !j(/ le,a CHECK If BILLING ADDRESS <br /> FM <br /> BUSINESS NAME �///®n � �j� PuViL"",�,yy 9�/Ji/� / //� <br /> HOME Or MAILING ADDRESS �f0 40Ox N�/eo yO IR "* -!i —007) (�(0j/ V? <br /> CIN 44011w�* STATE �(60 ZIP 7 SWei <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 <br /> or 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 FED E laws. �r <br /> APPLICANT'S SIGNATURE: DATE: It Ir— l+ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MAI ER ❑ 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or enviromnental/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: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />