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SAN JOAQUI -OUNTY ENVERONMENTAL HEALTH E�ARTn1ENT <br /> SERVICE REQUEST / <br /> FACILITY ID# LERICE REQUESpT# <br /> Type of Business or Property � Q-�j : <br /> OWNER/OPERATOR , CHECK)f BN.LING ADDRESS <br /> FACILITY NAME <br /> SITEADDRESS <br /> N, r v e/l G-- A;!51 <br /> _ Street SweName city <br /> et Number Direction <br /> HOME Or MAILING ADDRESS (If Different from Site Address) [/ <br /> itreet Number - Street Name <br /> STATE ZIP <br /> Clrr (GQ <br /> � Exr. APN# LAND LIGATION <br /> PHONE#1 <br /> (2 <br /> F� BOS DISTRICT LOCATION CO <br /> PHONE#2 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> VREQUESTOR / �� CHECK if BILLING ADORESSO <br /> ME33 - 65Z3 <br /> FAx# 334— Z61/ <br /> IN ADD SS L QZ CZ0 )[�, GI LJ STATEZIP(� <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 j <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 /> DATE: <br /> APPLICANT'S SIGNATURE: �� <br /> PROPERTY/BUSINESS OWN ER OPERATOR/NIANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BmUNG PAH7T 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 JOAQRIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same lime it is <br /> provided to me or my representative. ✓1 <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> Cr �yf( :.AUG <br /> SAENVI MENry1ENT <br /> ��/7Jii1 �4 IiEALTH DEP �I <br /> ACCEPTED BY: EMPLOYEE#: 4p DATE: <br /> D Z <br /> ASSIGNED TO: <br /> EMPLOYEE#: // DATE: Z �S <br /> �3Y <br /> Date Service Completed (if already completed): SERwcECoDE: / PIE: �_j <br /> Fee Amount: `� Amount Paid. I �L Payment Date OS <br /> Payment Type Involce# Check# Received By. _ <br /> EHD 4M2-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />