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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Buslness or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OFYRATOR <br /> � CHECK H BILLING ADDRESS <br /> /n\ <br /> FAciuTYNAME 1 o, �/:-JS `/_S4a�rq,a 1., <br /> SITE ADDRESS IIv V Sl 5��' �I �0rakD �OGY�tDr1 �I,OZ. <br /> Str••t Number Dlr•ctlo S • <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 'Sq Street Number N <br /> CITYsT I A TE CP zip ' Wt '� <br /> L.-+Vl.l- or r'lL- <br /> PHONE#1 "NO LAND USE APPLICATION N <br /> (4zs) 451-(Atpb <br /> PHONE 92 Er. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR S111� CHECK H ADM <br /> S$0 <br /> ADS!❑ <br /> BUSINESS NAME T1 P ONE# Err. <br /> 7111 C"Aor o�rV�h ILLL �tt uS)-(,t(olo <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY U,vtx rQ STATE CA ZJP g4i"S0 <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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURREE. i DATE: // 7 <br /> PROPERTY/BUSINESS OK'NERI OPERATOR/b1ANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IjAPPLICANT 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 environmental1site 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: ; ^��• ��(" t GL (� <br /> COMMENTS: <br /> HEyA <br /> tv Rp CO0 <br /> ACCEPTED BY: �t(�/L L` EMPLOYEE#: DATE: I < �� Nry <br /> Yl1 ENr <br /> ASSIGNED TO: p`t� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ) /E: <br /> Fee Amount: — Amount Paid /S'-) d� Payment Date <br /> Payment Type Invoice# Check# l 3 Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />