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s`aN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATORNt.t></'I LC �R� <br /> CHECK if BILLING ADDRESS❑ <br /> ,e i � y <br /> FACILITY NAME <br /> SITE ADDRESS ecS l dkc good Tra.�� 7-7 <br /> Street Number Dirtion �(n Street Name Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT' APN# LANDSEAPP CATION# <br /> ( ) z0�j - 2-1/0 -LSA ryf <br /> PHONE#2 Ext. BO$DISTRICT LOCATION CODE <br /> I ) CfC <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> a C// CHECK 11 BILLING ADDRESS <br /> B <br /> BUSINESS NAME SIEGPHONE# EXT. <br /> G,G/(�l� N6/N L�E�NG ( Uri ) 2z zi <br /> HOME or MAILING ADDRESS FAX# <br /> vUL/ Com�aQv AvC (mg ) 9Y,t b z / <br /> CITY S 7D GATT)/✓ STATE C. ZIP 9,5- Zo el <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. p `/ <br /> APPLICANT'S SIGNATURE: �(�{ / DATE: <br /> rr <br /> PROPERTY/BUSINEss OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IJAPPLiCANT is nor the BILLING PARTYProof Of aut/mrilatiOn to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: if 7 T <br /> COM ENT$: (T <br /> U ?IPA <br /> COUNTY <br /> SA34 NpA pNtNj,ENTPENT <br /> 7J E LTN OEPAgTM <br /> ACCEPTED BY: EMPLOYEE#: C?&Clq DATE: <br /> [ l <br /> ASSIGNED TO: EMPLOYEE#: L DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: r/� P I E: CJ <br /> Fee Amount: Amount Paid �p �� -� Payment Date <br /> Payment Type - Invoice# Check# 3D-7:3-7Received By: 7L. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 - <br />