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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Co Y I q 3 S(zo<) o5-33 ) <br /> OWNER/OPERATOR (bV <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME .y' \ <br /> QV�� \�O\,NCA`�) <br /> SITE ADDRESS \ ` 1 ' I �� <br /> Street Number Dir on `"f•Q�.��";\` S` treet ame V� <br /> HOME or MAILING ADDRE S\(If Different from Sile Address) <br /> V (wh'►{1 lJ1/ Street Number Street Name <br /> CITY&Q <br /> STATE ZIP <br /> PHONE#1c6 <br /> � �� �,�EXT, AP�# � � LAND USE APPLICATIONayl # <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME i NE P EXT. <br /> s L y y- <br /> HOME or MAILING ADDRESS FAX 4' ` <br /> CITY .1� STATE zip <br /> BILLING ACKNOWLEDGEMENT: 1, 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 <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FE ERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: t <br /> PROPERTY/BUSINESS OWNER❑ V OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT IF <br /> Y <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 samf time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: JUL <br /> 50 JOAQUtN COUNTY <br /> E"ROMMENTA N' <br /> DEPAR <br /> ACCEPTED BY: C • EMPLOYEE#: DATE: `7 <br /> ASSIGNED TO: I� T EMPLOYEE#: DATE: ( I ' <br /> Date Service Completed (if already completed): SERVICE CODE: /fv P I E: 2 U <br /> Fee Amount: S Amount Paid T375-,u-b Payment Date <br /> Payment Type Invoice# Check# 13 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />