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SAN JOAQU'. ,OUNTY ENVIRONMENTAL HEALTI PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR1 <br /> ,-t CHECK If BILLING ADDRESS <br /> FACILITY NAME_ V <br /> 5 <br /> SITE ADDRESS .rl`I61 �' �Y'✓1lC�S'/ �j17� GtC)Oi/, ��j�,3 <br /> cv <br /> �3L rj CA Street Number Direction S C U I Street Name City Zip Code <br /> HOME or MAILINGADDRESS (If Different from Site Address) <br /> C (, <br /> -\G-\ e ' L7v Street Number Street Name <br /> CITY <br /> STA CIVa ZIP?S U <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (ZaQ ) q5e U <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSI�s NAME PHONE# q EXT. <br /> -e- -T- Cc" �� l Y1 24) <br /> HOME or MAILING ADDRESS FAX# <br /> (oC Clnan,ie Cl ( ) <br /> CITYLA ti,"!L)f <br /> STATE 4 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 /> I also certify that I have prepared this a cation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar S ATE and EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ // <br /> 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/sk'tte"assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at thtt�ti']le it is <br /> provided to me or my representative. A '1 ,AA <br /> TYPE OF SERVICE REQUESTED: n �/l � <br /> COMMENT <br /> Ty� ,O,q T`hry <br /> �iFNl <br /> ACCEPTED BY: , (1 EMPLOYEE#: DATE: <br /> ASSIGNED TO: I U /�� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ' P I E: i <br /> Fee Amount: 1�Z_ Amount Paid-.. ,.� Payment Date <br /> Payment Typei <br /> Invoce# Check# „ .L Received B ' <br /> Y� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />