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SAN JOAQUL, —'OUNTY ENVIRONMENTAL HEALTH _ JPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER OPERATOR <br /> /OP / <br /> C�1 G( I OI <br /> o CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> ,.ITE ADDRESS- - <br /> StreetNumber Direction unm City Zin COGe <br /> HOME or MAILING ADDRESS If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME q PHONE EXT. <br /> bf1C�� cvZ e\ o1( ( (0 O a n c,�(o� (�evk c� ,2LI U ZS 1 v - <br /> HOME or MAILING ADDRESS �.{ FAX# <br /> IC) Q t l t?' <br /> I 3 C=, /�Cl C - ( ) <br /> CITY �C7 C LA 'Szb'�' 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 <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: G�1 G 1'` sav\c V'L`Z DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> /f 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 avaPA at the same time it is <br /> provided to me or my representative. a 1El y <br /> TYPE OF SERVICE REQUESTED: VE® <br /> COMMENTS: D i d ?O�O <br /> MAR y <br /> HEAI,TM N/cp�N <br /> r"4fSAV JonQul pJ. <br /> EIMROE�RT <br /> TNDMETM <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> VCS `J <br /> ASSIGNED TO: F \ Y 1\ —L� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O(-Q..\ PIE: \WC)2 <br /> Fee Amount: Amount Paid �a � Payment Date4PI 3 L Z,D <br /> Payment Type ,� ,� �'!, �, Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />