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SAN JOAQUII,.,JUNTY ENVIRONMENTAL HEALTI,..WEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS El <br /> FACILITY NAME <br /> SITE ADDRESS I y.� _0 �b�� G6 / <br /> l (2A 9S1-Yo <br /> Street Number Direction Street Name Ci 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# LAND S@ PLICATION# <br /> ( 1 D - zzo- 3 LA PLICATION <br /> i <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ; CHECK if BILLING ADDRESS <br /> BUSINESS NAME � '- - PHONE#) <br /> HOME or MAILING ADDRESS FAX# / <br /> CITY STATE zip <br /> BILLING ACKNOWLEDGEMENT: I, the un ersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specificvIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business a� entified 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, TEand F aws. <br /> APPLICANT'S SIGNATURE: DATE: 3 —O <br /> PROPERTY/BUSINESS OWNS OPERATOR/It ANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLIC T is'-n-o is'-n- t 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: c-en <br /> COMMENTS: �� U �ECEIVED <br /> \. SAN JOAC"N COUNTY <br /> ENVIRONMER MENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: Q <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S PIE: <br /> Fee Amount: Amount Paid ��1 Payment Date 511310 <br /> Payment Type Invoice# Check# ?r$C Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />