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SAN JOAQUIN —')UNTY ENVIRONMENTAL REALTY!`EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 7Z-s -5�/f v o a 7 z L <br /> OWNER/ OPERATOR CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> �•G? �Y. �/UL-��/� �l Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. 11 BOS DISTRICT -11 LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> S'/A CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY V STATE ZIP <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: 1,11-'r DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGE4 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: 1(cl-L r COMMENTS: I /.r1 /�q Gl+iv ;vLv�. <br /> MAR 19 20 4 <br /> Y/ -- _ I SAN JOAOUIN COUNTY <br /> ./&AP- ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: L i �c t EMPLOYEE#: 3 ) DATE: �1 !v o <br /> ASSIGNED TO: v S EMPLOYEE#: L(`S'+� DATE: J> / <br /> Date Service Completed (if already completed): SERVICE CODE: J- PIE: <br /> Fee Amount: ��� O Amount Paid U U Payment Date 3 ( U <br /> Payment Type Invoice# Check# !`3 S Received By: l_ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />