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SAN JOAQLIIN COtJN'ry ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQtO EST Type of Business or Property FACILITY ID# SERVICE REQUEST# OWNER/OPERATOR -- CtiEcx i1 E31ruNG ADDRESS❑ FACILITY NAME SITE ADDRESS Street Number Dir ctior teat Name CityZI Ca HOMS Or,MAIWNG ADDRESS (i€Different from Site Address) t j Number $ro t Name CITY ( STATE zip PHONE#t ExT. TAPN# LAND USE APPLICATION# i PHONE#2 ExT BUS DISTRICT LOCATION CODE CONTRACTOR 1 SERVICE REQUESTOR REQUESTOR ( � % r �_. CHEci<if BILLING G ADDRESS LJ BUSINESS NAME 9 PHoNI,.# Exr. ? Ho, or AILING ADDRESS FAx#':r_ �CITY ,,��t! ��j STATE ZIP BILLING.: ACKNOWLEDCx>;,MEN'F: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site anchor project Specific ENV]RONMENTAL HEALTH Di-PARTNIENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and thatthe work to be performed will be done in accordance with all SATS JOAQUIN C:C)UN'f'Y Ora'i ante C"o(ks,S'tanaavdy ,STATE and P)i7ETt��vs APPLICANT' S SIGNATURE: DATE': PROPERTY i L{i Si1ESS OwtiNER❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT-❑ If APPII(ANT is not the BILLING PARTY.proof of authuri4ation to sign is required Title AUTIIOIRIZATKtN I'O RELEASE INEORMA11ON: When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentallsite assessment information to the SAN JOAWIN COUNTY ENVIROI+AIEN'FAi-HEALTH DEPARTMENT as soon as it is available and at the same time it I's provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: SA/YMpRQNiN CC)Ary AIT[�D MANIAC ACCEPTED BY: EMPLOYEE M. DATE: ASSIGNED TO: EMPLOYEE#: DATE; Date Service Completed (if already completed): SERVICE CODE; Fee AmountAmount Paid Payment Date s Payment Type Invoice# Check# Received By - , I EHL?45-02.025 SIR FORM(Golden Rod) REVISED 11/17f-2003 gib::