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SAN JOAQUIN COUNTY ENVIRONMENTALHEALTHDEPARTMENT <br /> r-\� SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATO <br /> � CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS �� p� <br /> Street Numb<<er Direction c-Cr e� , Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from S' Address) lQ� <br /> ld�6 CG,S— Street Number Street Name <br /> CITY STATE Zip <br /> PH0NE#1 ExT. APN# LAND USE APPLICATION# <br /> os oo(e <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HOME or MAILING ADDRESS_ FAX# Cv <br /> CITY STATE ZIP <br /> BILLING ACK.NIOWLEDGEMENT: 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. G <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICANT 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. l <br /> TYPE OF SERVICE REQUESTED: STS cc)/,js- L- C) <br /> COMMENTS: SIC L-q(iL <br /> ,41,4e- ND N S✓ A i&W!i?�P��T c'PY el-IV�lu� 7t 0whr& . EI VST <br /> . --m.!Nl nv12 �iC�API JAIC15 /167 T-r1W, t LL 7? �Gi�r <br /> JAN 9 2606 <br /> SAS baa U! <br /> ACCEPTED BY: EMPLOYEE#: DA .Li <br /> O c c u�c W'—�4 ®3 <br /> ASSIGNED TO: V 4,�J &,(A.AE EMPLOYEE#: Day^U DATE: C O <br /> {date Service Completed (if already completed): SERVICE CODE: �� 1 E: 2— <br /> Fee Amount: 10 q,3. 00 Amount Paid 3 Payment Date C:4\1 b <br /> payment Type t/ Invoice# Check# , p a� Receive By: <br /> EHD 48-02-025 SR EOLITH!(Gofdt n Rod} { <br /> REVISED 11/1712003 <br />