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f .�,i �,,..r+an:. —,.•..off .� <br /> SAN JOAQUIOUNTY ENVIRONMENTAL HEALTEPARTMENTQ. <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SRC 38 ;1,-LN= ;,: <br /> OWNER!OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACUM NAME j <br /> SiTEADDRESS0 <br /> `- Street Number D, ` ]�Stree)t Name GC't9'� —Zip Code <br /> NOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 E'tT APN# LAND USE A TION <br /> ( 1AlIq <br /> PHONE#2 EXT, BOS DISTFucT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR <br /> Le eyeCHECK ifBILLING ADDRESS <br /> e �.� <br /> BUSINESS RANEE PHONE <br /> b i <br /> HOME orMAILING AD KESS FAX# <br /> CITY �rSTATE ZIP <br /> 13ILLLNG 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, TATE and E L laws. ` <br /> APPLICANT'S SIGNATURE: r l^ <br /> DATE.• `1 ^ <br /> I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I MANAGER ❑ OTHERAUTHORizED AGENT <br /> IfAPPLIC.4NTis not theBILLINGPAR7Y proofofauthorization to sign is required Terte <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 availabl0 and at the same time it is i <br /> provided to me or my representative. PAYMENT � 1 <br /> TYPE OF SERVICE REQUESTED: F N <br /> Coe1MeNTs: ��oyr7G JUN 12004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL, <br /> HEALTH DEPARTMENT <br /> • a <br /> I <br /> i <br /> ACCEPTED BY: EMPLOYEE#: DATE: I <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 06PIE: 2- <br /> Fee <br /> Fee Amount: Amount Paid c3 r payment Date 0 <br /> Payment Type Invoice# Check# Receive By: <br /> EHD 48-42-025 SIR FORM(Golden Rod) <br /> REVISED 11/1712003 S <br />