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SAN JOAQU,.. —'OUNTY ENVIRONMENTAL HEALTL ,EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0177� Z <br /> OWNER/OPEqATOR � <br /> ) ^'C " 1(A CHECK If BILLING ADDRESS <br /> FACILITY NAME ` <br /> SITE ADDRESS <br /> 130 S Street Number Direction �`"�1 I r detTlame J Cit Zi Code <br /> HOME or MAILING ADDRESS f Different from Site Address) <br /> `-' W Street Number "` O Street Name <br /> CITY I— <br /> fi ronch Cam i%77 s z 3 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEG tv) '—S PHR�E ' �� EXT. <br /> HOME or MAILING ADDRESS LC FAX# <br /> P�Q ck ) <br /> CITY •l C L60012 <br /> STATE ,1 ZIP q c 3 <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: �Q '�2� A--x—'— 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, 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 ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available anaDliE same time it is <br /> provided to me or my representative. • M� <br /> TYPE OF SERVICE REQUESTED: j(1 �I Y�1\(� 111��t'C I v✓� oVF <br /> COMMENTS: <br /> 3 zo? <br /> y Ej y�RO U/H CoU o <br /> FACTy o pM�r4t <br /> Ifelo <br /> ACCEPTED BY: ^ EMPLOYEE#: DATE: .��. <br /> ti <br /> ASSIGNED TO: ,/ ` EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: C i PIE: <br /> Fee Amount: 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 />