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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> V�IV /VA 5 W- tA 100 aC j0 f I GJ 2? <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS / V qul" c0 ,5 <br /> Street Number Direction � St et Name Cit 2i Code <br /> HOMr MAILING ADDRESS (If Different from Site Address) <br /> 1100 Street Number Street Name <br /> CITY W STATE A ZIP <br /> / <br /> PHONE #1 EXT• APN # LAND USE APPLICATION # <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> c ) F2f � C, ZZI 11 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUES OR <br /> CHECK If BILLING ADDRES � <br /> BUSINESS NAME � r PHONE # EXT. <br /> (J Is cN <br /> HOMEOrAILING 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, Standa s, STATE and FEDERAL laws . <br /> APPLICANT ' S SIGNATURE : !2LV � DATE : 1 Z���i ' � m I <br /> PROPERTY / BUSINESS OWNER ❑ PERATOR / MANAGER 11THER AUTHORIZED AGENT rJ4 .44eo*� <br /> IfAPPLICANT is not AILLINNG PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEA 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 same time it is <br /> provided to me or my representative . + <br /> TYPE OF SERVICE REQUESTED : SU�LA oV L <br /> COMMENTS: pjC % O <br /> �GTy��pq����N� <br /> IFN <br /> ACCEPTED BY : E /h e { •�� EMPLOYEE #: CcDATE : <br /> ASSIGNED TO : !?� IXNj�� t r EMPLOYEE # : 0,o I DATE : <br /> Date Service Completed ( if already completed ) : SERVICE CODE : P I E : <br /> xQ <br /> Fee Amount: Amount Pal � �? d Payment Date 12.11 <br /> Payment Type Invoice # Check # Re eived . y <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />