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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 /> 1 n n C n ( CHECK If BILLING ADDRESS <br /> FACILITY NAME � N� �/ J <br /> SITE ADDRESS N IV ,�In S� ,��,�. �� 8533 <br /> 3 Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1^^ (A, <br /> Street Number r Y Street Name <br /> CITYQ r) w� SATE ZI <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (qQ) alb °I-]-7" <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> 1m•(o a heeOeA W;n �� 1 CHECK 11BILLING ADDRESS <br /> O J 1 J' <br /> BUSINESS NAME PHONE# . EXT. <br /> � LO 1 � <br /> HOME or MAILING ADDRESS FAX# <br /> 3 N 0,21n -{- <br /> CITY MtA l I CGS STATE ._.SII;n 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 HEALTI-1 DEPARTMP!NT 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 FEDERAL laws. l Q <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS ONVNE,R PERATOR/ ANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 andil> ame time it is <br /> provided to me or my representative. YMt w <br /> TYPE OF SERVICE REQUESTED: v a REG <br /> COMMENTS: I 0q1 1 <br /> NN <br /> SPN 3OAaU1MENTAL <br /> HATH pEPARTMENT <br /> ACCEPTED BY: ,M o Jin ro EMPLOYEE#: DATE: <br /> ASSIGNED TO: S • So w L� EMPLOYEE#: DATE: <br /> Date Service Completed (if al eady com ted): SERVICE CODE: S2, P I E: 101 <br /> Fee Amount: 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 /> PV° t'�'2-U '3 Sr <br />