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SAN JOAO' 'N COUNTY ENVIRONMENTAL HE :H DEPARTMENT <br /> lw' SERVICE REQUEST" <br /> Type of Business or Property FACILITY ID 9 SERVICE REQUEST# <br /> ADD � I <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> f! <br /> FACILITY NAME <br /> SITE ADDRESS <br /> ZZZ C)S Street Number Direction "r' �treet Name CI Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Ad TS) <br /> 2 2. . tI�7oY� Street Number Street Name <br /> CITY STATE ZIP <br /> 14cr C� �Szz o <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 2o-?) '4r, 3 - ZSoc aa3-090 -0-� <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> (zff ) v <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUE T R <br /> 1 CHECK If BILLING ADDRESS <br /> BUSINESS NAME t PHONE# EXT' <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY JO a STATE l2 F•�IP <br /> BILLING ACICNOA EDGEMENT: 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, S A E and FEDERAL laws. <br /> APPLICANT'SSIGNATU�R.�rE: % XA/C� DATE: ///q! /D3 <br /> PROPERTY/BusLNESs OWNER L'1 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> IfdPPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, L 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 environmentallsite 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. ENT <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: lle y� �yi�.,i / //�/� �na �..�� O" 1 9 7 <br /> i0 n=�_� _ �a++y TGG\ e e.• ESIP <br /> NNRONM XtA t5 <br /> N�LtN DEPP /i <br /> a3-ac . 3 <br /> ACCEPTED BY: EMPLOYEES DATE: Q <br /> ASSIGNED TO: EMPLOYEE : S3 DATE: <br /> Date Service Co pleted (if already completed): SERVICE CODE: � P1 E: <br /> Fee Amount; _ Amount Paid X43 Payment Date <br /> Payment Type Invoice# Check# �S/� Received By: - <br /> EHD 48-02-025 SR FOF_t_M_ (GddegRod) <br /> REVISED 11/17/2003 - <br />