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SAN JOAQUI, .:OUNTY ENVIRONMENTAL HEALTI-I&PARTMENT <br /> SERVICE REQUEST <br /> Type of Busi ess or Property FACILITY ID# SERVICE REQUEST# <br /> '� ws 1 lo�-t <br /> Ow ERAT <br /> \A-\ 7PV \` fCV e CHECK If BILLING ADDRESS <br /> FACILITY NAME v I 1 <br /> SITE ADDRESO ,�� 5 S c cr 3 <br /> rest Number Direction a it i ode <br /> HOME or MAILING ADDRESS (1 ifferent fro Site / IAddress) <br /> Il/� "( C h r 1 Street Number Street Name <br /> CITY. , S(!Tf 1�) <br /> PH NE#I APN# LAND USE APPLICATION# <br /> s E 15-956a <br /> P ONE#; r\ ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUEST <br /> ` 1\' d�� CHECK If BILLING ADDRESS L� <br /> BUSINESS NAME —^ CO � ht 2111 aC6 <br /> PHONE# EXT. <br /> HOME Or MAILING ADDRESSI� © _ 1 e eM Lrl <br /> PAX# ) <br /> CITY �_ \ 7 STA [_ zip C-1 !�C <br /> BILLING ACKNOWLEDGEMENT: 1, 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ,t {' . DATE: <br /> T <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, 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. A <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: J4 B, F® <br /> tis Ni.°gQ��s� Q <br /> �4THo�pgRN q4 �Y <br /> M <br /> ACCEPTED BY: V`�� `� EMPLOYEE#: DATE: 2-0 <br /> ASSIGNED TO: '-- 41 V �Lw EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: J� P I E: f 6 v 7 <br /> Fee Amount: �(�'' G� Z C1 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 />