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SAN JOAQUIN _,OUNTY ENVIRONMENTAL HEALTH 1 -'ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> G <br /> OWNER/OPERATOR <br /> Al-O ^ /` , � J O !C Q r 6 a r� CHECK if BILLING ADDRESS <br /> FACILITY NAME A /v �/�rSIIAS cs � N���3 <br /> SITE ADDRESS (� <br /> TM Number Direction Street Name Clt Zi Code <br /> HOME orMAILING ADDRESS (if Different from Site Address) ��''r <br /> 2'9�� L /? �—GL / Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> Iy ) y3 f <br /> PHONE#2 ExT. BOS DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> U ( CHECK if BILLING ADDRESS <br /> BUSINESS NAME ,{ PHONE# EXT. <br /> HOME or MAILING ADDRESS :`q!, I I FAX# <br /> U ( ) <br /> CITY STATE CA ZIP S�v� <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 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: 4/ 77—;7A/ C2 4 j/f},LA— DATE: //'Z,:. <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT 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 t&4x same time it is <br /> provided to me or my representative. / �r <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> A4Nry <br /> MFHT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: <br /> Date Service Completed (if already completed): SERVICE CODE: O PIE: 1(00--2 <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 />