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SAN JOAQUIN _ -OUNTY ENVIRONMENTAL HEALTH MARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ERVICE REQUEST# <br /> SN 010071)2F <br /> OW R/OPE TOR <br /> n ` ` CHECK if BILLING ADDRESS El <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 2 C-) N('k W: Street Number Street Name <br /> CITY 1 J STATE cikl �ZIP2—c L <br /> PHONE#1 EXT77 APN# LAND USE APPLICATION# <br /> (RA) �1-?^ Z63'--( <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME` Y� PHONE# EXT. <br /> r�D�s ALL 6i k)7- s� <br /> HOME or MAILING ADDRESS FAX# <br /> Z 6, GkN C ( ) <br /> CITY t� ( STATE ZIP <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 /> 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, ]I= <br /> laws. <br /> APPLICANT'S SIGNATURE: �q{ <br /> DATE: ( /to <br /> PROPER'Il'/BUSINESSOWNERP PERATOR/NIANAGER ❑ OTHER AUTHORIZED AGENT <br /> !(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. P <br /> TYPE OF SERVICE REQUESTED: 2612 011Ck <br /> �� CN <br /> COMMENTS: <br /> AFP U <br /> G ?0 <br /> hN('lR Q�/H C �9 <br /> TyDFpq���Iy�Y <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: I EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 5'' pit: <br /> / l] <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 />