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SAN JOAQUIN(•NTY ENVIRONMENTAL HEALTH DE TMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �(zoo40S� <br /> OWNER/OPERATOR )/ / <br /> /e CHECK If BILLING ADDRESS <br /> FACILITY NAME 7 <br /> / 14 <br /> SITE ADDRESS <br /> ircRY'" - � <br /> Street Number Direction Street Name C ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) I <br /> IZ�) Street Number �' 7vv Street N me/ <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ,s <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> I ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR oL CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> l ) <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledee that all site and/or proiect specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this appft*onandt the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standgc% AL laws. / <br /> APPLICANT'S SIGNATURE: DATE: d <br /> PROPERTY/BUSINESS OWNER OPERAT / A OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the B/CLING 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: Cot)"/3 U Lt Lrtti1 af r--Cj-- <br /> COMMENTS: <br /> DEC - 6 2004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: OL-1 EMPLOYEE M 15)31( DATE: �2 &(0 <br /> ASSIGNED TO: 6 EMPLOYEE#: 0 <br /> -4L,7 <br /> DATE: 1&(o <br /> Date Service Completed (if already completed): SERVICE CODE: S�`� P/E: <br /> Fee Amount: i7 Amount Paid �' — Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />