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SAN JOAQUIN COUNTY tNVIRONMENTAL HEALTH!)EPARXINIENT <br /> I or Vo <br /> ;P. ,f <br /> EDSERVICE REQUEST � l <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> �i CHECK if BILLING ADDRESS E] <br /> FACILITY NAME <br /> SITE ADDRESS .-C_ <br /> (-SCC:} � /3 k- � �.I`��i � --2— � t ItiC'���L� lf�`CO <br /> Street Number Direction street are Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> �� .\\`�' ��� Street Number Street Name <br /> CITY i STATE ZIp. <br /> PHONE#1 ExT. APN# <br /> LAND LI5E APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATkON COD@ <br /> CONTRACTOR/ SERVICE REQUESTOR C <br /> REQuirsTOR <br /> CHECK If BILLING ADDRESS D <br /> BUSINESS NAMES PHONE# EXT. <br /> ( ) <br /> HOME or MAILING ADDRESS FAX# 4 <br /> CITY STATE zip IN <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 oli 's form. �C <br /> I also certify that I have prepared this app 'cation an t e wor be pe rmed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TE and <br /> APPLICANT'S SIGNATURE: DATE: �° A�) <br /> PROPERTY/BUSINESS OWNER❑ ERAiroR/NIANAGER OTHER AUTHORIZED AGENT❑ <br /> ifAPPLICAN not CBILLIN_ G PAR TY 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: � ( � � t � w X5'7�- GU A)J Lt-C—~s,=?7 0 1J <br /> COMMENTS; <br /> o tied S�%T7 G- s s � ' 7- <br /> -' u�tit � � 3 - <br /> ACCEPTED BY: �] E,_) r kA EMPLOYEE M. DATE. ' <br /> ASSIGNED T0: S L� EMPLOYEE#: DATE: <br /> J� 5c �t [ f,o G� <br /> Date Service Completed (if already completed): SERVICE CODE: (p f P l E: `f?-V° <br /> Fee Amount: I _ Amount Paid T Payment Date d <br /> I <br /> Payment Type Invoice# Check# q Received By: <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 - �Q�jl�` Sf7 FCf {Gofdei Rod) <br />