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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTIj DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> I <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> _ .may�,,. /J <br /> FACILITY NAME r-19-1— Artl (�%+� U/ c <br /> SITE ADDRESS <br /> t ✓ Name �tj �� �J p� �`� <br /> Street Number I Direction <br /> Zip Code <br /> HOME or MAILING ADDRESS (If Diffe►ent from Site Address) <br /> 1 " �2Street Number Street Name <br /> CITY �-- (GSTATE ZIP <br /> PHONE#t ExT APN R LAND USE APPLICATION <br /> PHONE 92T BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS E] <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FpAX# <br /> 1 1 <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,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ��' DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> I•f APPLICANT is not the BILGING 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: GtJ�I4 v O <br /> F�� 6 2pp4 <br /> � 1 <br /> / gPN JD Rc1401E.14 <br /> ACCEPTED BY: EMPLOYEE DATf .flC <br /> ASSIGNED TO: ,EMPLOYEE#: .'Z I DATE: <br /> Date Service Completed (H alrea c ted): SERVICE CODE: PIE: <br /> Fee Amount: 7j Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />