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SAN JOAQUL, —OUNTY ENVIRONMENTAL HEALTH ._—PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property t. FACILITY ID# SERVICE REQUEST# <br /> Sk 0 <br /> OWNER/OPERATOR <br /> f I CHECK If BILLING ADDRESS <br /> FACILITY NAME �/ 1 <br /> SITE ADDRESS *"' s r; <br /> 'r Nuh'' treat Name <br /> A "' L^ <br /> Street mber D action t Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Ot Street Number Street Name <br /> CITYr STATE ZIP <br /> S O C� N 252/2- <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( I 61P q,32W <br /> . <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 52-0 S <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> J y CHECK If BILLING ADDRESS <br /> BUSINESS NAME I PHONE# �/ / EXT. <br /> r <br /> HOME or MAILING ADDRE S FAX# <br /> q150 �1- <br /> CITY S l �— STAT ZIP 12— <br /> BILLING <br /> Z <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 forth. <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, STAT and FEDERA laws. <br /> APPLICANT'S SIGNATURE: <br /> % it DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MA AGER ❑ 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 antisame time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: �b�� <br /> COMMENTS: O <br /> 3 <br /> &M�RU/ry 4 <br /> ThOUU <br /> � <br /> 7YwuG Co <br /> MINT <br /> ACCEPTED BY: I avirn <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: /Jm,in , EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: G PIE: <br /> Fee Amount: I(5;- 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 />