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SAN JOAQUIN k- ,t,JNTY ENVIRONMENTAL HEALTH D'G, nRTMENT <br /> SERVICE REQUEST <br /> Type of Business or Propem; FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME Ajo <br /> a a I <br /> SITE ADDRESSi�-!J b T ��ytrf1 r� fi(r ��j <br /> Street Number rectio l "1 lStreet Name cityZI Code <br /> HOME or MAILING ADDRESS (if Different from Site/A]'ddress) <br /> ' ' a e� lir,r Street Number Street Name <br /> CITY � STATE � ZIP <br /> PHONE#1 ExT APN# LAND USE APPLICATION# <br /> ( SIO) 2�5l12 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> c1l—35 <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR O <br /> � 'CA <br /> CNECK If BILLING ADDRESS <br /> BUSINESS NAME V n r Troe-t— PHONE# f� Exr. <br /> � <br /> HOME or MAILING ADDRESS 1�V 1 FAX# L!I <br /> CITY "n STATE ZIP 11G,20 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 [ have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQIJIN <br /> COUNTY Ordinance Codes,Standards, T d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ---- DATE: <br /> rL16 / <br /> PROPERTY/BUSINESS OWNER OPERA OR/MANACER ❑ 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, 1, 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 enviLo/nlmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availablRAYW[ITe time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: WA <br /> J [ G <br /> COMMENTS: 1.r <br /> SAN JOAQUIIV COUNT y <br /> ENV►RONMENTAt <br /> N1:AI_TH DEPArj AL <br /> ACCEPTED BY: 4r} EMPLOYEE#: DATE: <br /> ASSIGNED TO: v EMPLOYEE M DATE: <br /> Date Service Completed (If already ompleted): SERVICE CODE: D P I E: Vi\ <br /> Fee Amount: ',52 I <br /> Amount Paid Payment Date D (COM <br /> Payment Type 8 v` Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />