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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> J0 <br /> i_^n\ CHECK If BILLING ADDRESS <br /> , C� '1 <br /> FACILITY NAME <br /> SITE ADDRESS r /Z I\ r1 C`r� �jsL ZCs <br /> _ C T, J Fi <br /> �L'S I4= Street Number Direction 1 Street Nam t 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 USE APPLICATIO # <br /> ( ) ,3 - 9o0I 21 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) 4- <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> t3G.l\� .,' h 4VLL!( CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ' b 3 3 5 r ( ) <br /> CITY I Ci n U STATE C ZIP 1 ZC <br /> BILLING ACKNOWLEDGEMENT: 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 <br /> or activity will be billed to me or my business as identified on this forth. <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 FELE L laws. <br /> APPLICANT'S SIGNATURE: L Lf DATE: I l l s �� `t <br /> PROPERTY/BUSINESS OWNER❑ E �Rl MANAGER ❑ OTHER AUTHORIZED AGENT❑/fAPPLICANT i the BILLINGTY 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: ( p <br /> COMMENTS: <br /> � <br /> �MENT <br /> R <br /> eiv <br /> NOV 15 ?01,9 <br /> VAN SQA <br /> ACCEPTED BY: EMPLOYEE#: H �� <br /> ASSIGNED TO: EMPLOYEE#: DATE: NT <br /> Date Service Completed (if already completed): SERVICE CODE: P I E:�d <br /> Fee Amount: (f Amount Paid �j a Payment Date <br /> Payment Type Invoice# Check# f� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />