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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> i so/ <br /> SITE ADDRESS p 4o ,, 1 ] ., „f; Ave T �CJ /I LI1� <br /> Street Number Direction T W LSttrre`et•Ntame {/CLit (/� Zio Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> f� ( Street Number Street Name <br /> CITY STAT ZIP <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# Jt� <br /> ion) 9 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Ak i ��a u <br /> HOME or MAILING ADDRIESSU d FAX# <br /> W J-4)6.0 Ale ( ) <br /> CITY STATE ZIP 9. 0 <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 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 nd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT 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. <br /> TYPE OF SERVICE REQUESTED: ::Zj S Pqy <br /> COMMENTS: <br /> J <br /> SAN 020 <br /> E110AQUIN <br /> HE <br /> ALTy Cp <br /> DNMEN7 / <br /> ACCEPTED BY: �01 i ,1 (0 EMPLOYEE#: /� DATE: <br /> ASSIGNED TO: r VLn l/l EMPLOYEE#: V DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid a Payment Date <br /> Payment Type Invoice# Check# d�CJ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />