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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT , 2� 4k <br /> SERVICE REQUEST �• <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �r:.Soct� Iks -% FACILITY <br /> OWNER/OPERATOR `� CHECK if BILLING ADDRESS❑ <br /> --VQ 11 ,t a « �tSo uL�C \0,#2; �a '�q.L . <br /> FACILITY NAME c ^N W5 04t4OJ` <br /> S(Eb �� ►��.,� YZa� hocE AD Ca i °45 X0 <br /> Street Number Direction Street Name cityI Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE LP <br /> PHONE#; ^ APN S 1 ^� LAND USE APPLICATION# <br /> PHONE#2 EzT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR /SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT <br /> HOME or MAILING ADDRESS FAX# <br /> ( 1 <br /> CITY STATE LP <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 DEPARIMLNT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 also certity 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,STATL and FEDE2AL aws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> �r,. <br /> PROPERTY/BUSINESS OWNE OPE OR/ GF:R ❑ OTHER Al'1'HURIZEU��G F.VT❑ yw �R+�t <br /> ff APPLI A,vT is not the BILLA"G PARn,proof of authorization to sign is required Tide <br /> e <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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAi.HEALTH DF.PARTMF.NT as soon as it i5 available and at the sante time it Is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: r�` <br /> a <br /> COMMENTS: <br /> C <br /> HFA�TH p�p�9�yT��N1Y <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �� P I E: 021, <br /> Fee Amount js� �� Amount Paid ' 0 Payment Date <br /> 1 r <br /> Payment Type Invoice# Check# /O Z� , Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />