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SAN JOAQUIP OUNTYENVIRONMENTAL HEALT 1EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> N&TTI & 144c-C, -'/2A, C CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS /S000 <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 0/11-e 7-C/2,5 44AI btell 6 <br /> Street Number Street Name <br /> CITY alloc-cu S STATE N' ZIP / 3 Z,6 -2- <br /> PHONE#t ExT. APN# LAND U;g APPLIC TION# <br /> (31 ") y7/ - S339 ' zy� — Z� a(/ <br /> 13 � <br /> PHONE#T EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1 <br /> 140 <br /> C/� CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT- <br /> 4! <br /> 59W11VCe41--V6 9 y3— z�lt! <br /> HOME Or MAILING ADDRESS FAX# <br /> 0 (.2—K) <br /> CITY ! C _ STATE 64 ZIP '94; 2 A <br /> Jt <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 la S. <br /> APPLICANT'S SIGNATULlJdG/ <br /> RE: DATE: " L<—O 4- <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 ava%AYfOt" same time it is <br /> provided to me or my representative. RECEI V <br /> TYPE OF SERVICE REQUESTED: <br /> r � � JUIN 2 <br /> COMMEHTS� ,1 <br /> O tip,--.n (f `" I SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> t , <br /> ACCEPTED BY: C -EMPLOYEE / �4 DATE: J V <br /> ASSIGNED TO: EMPLOYEE#: / T DATE: Z d I <br /> Date Service ompleted (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: 4j Amount Paid ' Payment Date Lo. <br /> Payment Type Invoice# Check# 3Dg1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> owiccn 41 i--- <br />