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SAN JOAQUII' <br /> *WW AUNTY ENVIRONMENTAL HEALTF ',Pq <br /> RTMENT <br /> Type of Business or Property SERVICE REQUEST , <br /> FACILITY*I_D# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> FACILITY NAME v"' 1 CHECK if BILLING G A_ oDRESS E3 <br /> SITE ADDRESS r� n <br /> ILI <br /> Street NumberDirection n 7�/ v LL ^_ <br /> Street Name �mG �sd� <br /> HOME or MAILING ADDRESS (If Different from Site Address) CI <br /> Zi cod/ <br /> CITY Street Number <br /> Street Name <br /> STATE ZIP <br /> PHONE#1 <br /> ( ' n / APN# LAND US APPLICATION l <br /> PHONE#2 L/' ExT. <br /> ( ) BOS ISTRICT (� LOCATION CODE <br /> 1 <br /> REQUESTOR CONTRACTOR / SERVICE REQUESTOR <br /> 13�^ �� CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HOME Or MAILING ADDRESS F � <br /> / FAX# <br /> CITY � � i� ( ) <br /> STATE zip <br /> LE GEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> BIL6NG A=0W <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 ap 'cation and that the wo to e performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards TA FEDERAL Ia s. <br /> APPLICANT'S SIGNATURE: ���, ,/ DATE: -4�z <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/M AGER OTHER AUTHORIZED AGENT El <br /> If APPLICANT is not the BILLING PAR of 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 aphe same time it is <br /> provided to me or my representative. YJ�Alj� <br /> JV <br /> TYPE OF SERVICE REQUESTED: RE <br /> COMMENTS: <br /> �OUNjy <br /> 3�AONMEWISL <br /> - ENf <br /> EN H OEppt�VM <br /> ACCEPTED BY: EMPLOYEE#: DATE: / 2.— 3 a <br /> ASSIGNED TO: / ��{ c„ EMPLOYEE#: / DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 7 Z P 1 E: � <br /> Fee Amount: Amount Paid Payment Date 3 B <br /> Payment Type Invoice# Check# ZZ ILS I <br /> Re eived By: <br /> EHD 48-02-025 X/t,, �+ D SR FORM(Golden Rod) <br /> REVISED 11/17/2003 3� <br />