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SAN JOAQUIN rOUNTY ENVIRONMENTAL HEALTH nEPARTMENT <br /> SE�VYLE REQUEST -- <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �lv <br /> OWNER/OPERATOR <br /> etn CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESp /� f G J / <br /> -DW 3 Z– -j6 v ' " IPL n u ref Seoc q �a `7 <br /> Street Number Direction I citv Zip Code <br /> HOME or MAILING ADDRESS (If D' Brent from Sit ddress) <br /> t yv� Street Number <br /> -XWA.VBet Name <br /> CITY $TATE, _ ZIP TGv <br /> PHONE#'I Exi. qpN# LAND USE APPLICATION# <br /> ( ) <br /> D3 C� <br /> PHONE#T EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> c– CHECK if BILLING ADDRESS CI <br /> BUSINESS NAME �J PHONE# / EXT. <br /> ( ?s` f,4G <br /> HOME or MAILING ADDRESSFAX# <br /> CITY STAT ZIP c <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. <br /> APPLICANT'S SIGNATURE: l/(�� Lit C C— DATE: / 3/ (0, <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/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 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 /> r^ Z <br /> COMMENTS: � – 3 - (�S %� RGv <br /> 125p6 T Jt � ✓ G�- AN 3 1 ins <br /> m F vsarzZo y <br /> lI-*"* COUNN <br /> SA EN0 QUINS <br /> OS TMEM <br /> STN DEPAR <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: r C –� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: / P I E: 2 <br /> Fee Amount: g Amount Paid Payment Date l 3((�S <br /> Payment Type ✓ Invoice# Check# t s Received By: <br /> zel— <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />