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( q s 6 <br /> SAN JOAQUI, .OUNTY ENVIRONMENTAL HEALTH . PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OW ER/OPERATOR <br /> ( I �\ \- \ J C" CHECK if BILLING ADDRESS E] <br /> FACILITY NAME ���1111 <br /> SITE ADDcRESSC u no � V e V a� J C� <br /> J Street Number Direction treet Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#f EXT. APN# LAND USE APPLICATION# <br /> (z,:1 ) Nq3-7554 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> -703 & <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUEST R /� <br /> �` t �y\ Y ; CHECK if BILLING ADDRESS <br /> BUSINESS INVccM 1 �n1 P N #) < EXT* <br /> 7 f � cc S I� C � 4 C" <br /> HOME or MAILING ADDRESS (� FAX# <br /> 1 S L(,'C k) FT lJ ( ) <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 DEPARTMEN'r hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 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, ST TE^andFEDERAL laws. <br /> APPLICANT'S SIGNATURE: C� DATE: <br /> PROPERTY/BUSINESS OWNN.1O OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tule <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 DEPARTMEN'r as soon as it is available and ne time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: VAC 0 <br /> COMMENTS: Pati GI !i 1�F / W►�� I O� �� lD�i� V Y cA lv-e SANdo, "020 <br /> 'tw�s t Ol J Gl ���(���- HF'gCriy pME�°TA N� <br /> �n��+n.ce 1 � P <br /> �RTMENr <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: '2Al,� 2!D <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: 1\00 <br /> Fee Amount: , i =� .-- Amount Paiowq D� Payment Date <br /> Payment Type Invoice# Check# �d`j 2� Received By: <br /> EHD 48-02-025 �S�i SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />