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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> .3X o (005s-D <br /> OWNER I OPERATOR <br /> -r CHECK If BILLING ADDRESS <br /> FAcUTy NAME <br /> SITE ADDRESS L lT� Lp WO--, 5aC`t'ia 6© ` �^' 9' 'r 2-42- <br /> 128Z8 N- Street Number Direction Street Namecity Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> I� <br /> 1� '0 (2>0Street Number L©�' Street Name <br /> CITY STATE ZIP <br /> �. A 9V 2 <br /> PHONE#1 E.T. APN# LAND USE APPLIC ON# <br /> ilPHONE#2 EXT. BONS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR M � 10\ U CHECK if BILLING ADDRESS� <br /> BUSINESS NAMEPHONE# EXT. <br /> `rEC-h Nt C,�L C 016 ) ) o <br /> HOME or MAILING ADDRESS FAX# <br /> 2 -6rJ ( O -ZO n ``c <br /> CITYSTATE 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 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, STATE and FEDERAL laws. f <br /> APPLICANT'S SIGNATURE: DATE: i <br /> PROPERTY I BUSINESS OWNER❑ OPERAOR I MANAGER ❑ 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAt..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: �� Av imS�5PAYMEN I. <br /> COMMENTS~ RECEIVED <br /> JUL 2 o zona <br /> foSAN�j JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> I"\HEALrH DEPARTMENT <br /> ACCEPTED EMPLOYEE#: ����� DATE: <br /> ASSIGNED TO: fEMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type ✓ Invoice# Check# `110 0 L.` Received By: ... <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />