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SAN JOAQUII�7UNTY ENVIRONMENTAL HEALTV''EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 7 r 7�///(, -1:z �R 40 4qq(., <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> 31)61�N 11A 41 i1y�l <br /> FACILITY NAME 7 `/ P C# ./Cq/�1 6— <br /> SITE ADDRESS &S3 / 7 Al IVS C f S//Ck'Alt�f <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> 9793 i'/Isn fi��c7 <br /> Street Number Street Name y <br /> CITYSTATE ZI <br /> i <br /> `�1167C / P <br /> PHONE#I ` Exr. APN# LAND USE APPLICATION# <br /> 700/ <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> 2-7000 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT' <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <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 or <br /> activity will be billed to me or my business as identified on this form k <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 SIGNATUREZ ' DATE: II -as <br /> PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILyNG 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: PAYME V <br /> COMMENTS: <br /> NAV 2 g 1005 <br /> SAN JOAOOIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: � EMPLOYEE#: X373 DATE: <br /> ASSIGNED TO: ��` � EMPLOYEE#: 8,373 <br /> 373 DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: O� ( P 1 E:11 /603 <br /> Fee Amount: Amount Paid 0� n Payment Date <br /> Payment Type " Invoice# Check# D Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />