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SAN JOAQUIN -OUNTY ENVIRONMENTAL HEALTH L .'ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> rzc �S FA �t�( pfZ <br /> FACILITY NAME <br /> W( 2 - CA-Ft= <br /> SITE ADDRESS � � (, � 0 rZ A�0 S�- �T 0 G(L -('-0►.( C(S L O L <br /> 3 Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR '^r 1 C A,6,4 1 1 I A L i_r CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME Y I/t ��/ "1 PHONE# EXT. <br /> �A1At-�0rt �ik IPAEF-t?I .�r�cC S16 333 - tlsL <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 0 STATE �, Q ZIP S6 R <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 FE RAL laws. <br /> APPLICANT'S SIGNATURE: DATE: �t�{ d �o <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT C Q -t-'�Z A�LJrD ti <br /> IfAPPL/CANT 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. ,� 1 <br /> TYPE OF SERVICE REQUESTED: O (4 t�C ST- t2� s r CEtvEC C <br /> COMMENTS: APS c� u 20OU <br /> H L+QU`N GOUN� <br /> SANS RpNPA1MENT <br /> H��1N DE <br /> ACCEPTED BY: L t L t EMPLOYEE#: C 3 DATE: Z Q t.) <br /> ASSIGNED TO: EMPLOYEE#: S ( DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: /`U PIE: <br /> Fee Amount: Amount Paid Payment Date I <br /> x-74. i <br /> Type Payment T e Invoice# Check# Received By: <br /> Y � ;-' <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />