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SAN JOAQU- BOUNTY ENVIRONMENTAL HEALTL EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Za 512, 2cc s -� ( . C <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME - <br /> , <br /> SITE ADDRESS // S <br /> 0/3 Street Number Direction �V Street Name T Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1- Exr. AP # ��3 O ` � LAND USE APPLICATION# <br /> 3 1/Y[J/ <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) Vo <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR <br /> y��i�_•��� CHECK If BILLING ADDRESS <br /> V <br /> BUSINESS NAME !� � PHONE# Ex'r. <br /> HOME or MAILING ADDRESS / FAX# <br /> CITY STATE ZIP <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 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, T and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: os.� -SZ- DATE: ek <br /> PROPERTY/BUSINESS OWNER❑ OPERA R/ bIANAGER 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. T <br /> TYPE OF SERVICE REQUESTED: RECEIVE <br /> COMMENTS: 1,-5 <br /> Ci OAQUIN COUNTY <br /> SAENVIRDEPMA WE <br /> HEALTH <br /> ACCEPTED BY:T, VM EMPLOYEE#: DATE: /� O <br /> ASSIGNED TO: (2 V I EMPLOYEE#: DATE: 111d <br /> Date Service Completed (if already completed): SERVICE CODE: PIE:21061 <br /> Fee Amount: 3 l '�, UU I <br /> Amount Paid I e Uv Payment Date ( (uS <br /> Payment Type U S Invoice# Cheek# � � 1 211 Received By: T. <br /> EHD 48-02-025 — SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />