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SAN JOAQU- —'OUNTY ENVIRONMENTAL HEALTIk. —EPARTMENT <br /> SERVICE REQUEST <br /> Type of Bum ess or Property FACILITY ID# SERVICE REQUEST# <br /> Uvc� f Ck Seo 0 �k \��-2 co <br /> OWNER/OPERATOR <br /> -^ rA �7 CHECK If BILLING ADDRESS <br /> YIA <br /> FACILITY NAME � �. �- T i V! <br /> SITE ADDRESS J I Ili I /0's <br /> t3-�-3 <br /> DCESS <br /> 3 Street Number Direction treet Nam Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> Ds <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ,�^ \- �(` \ ,, <br /> n r\ \ \ t Q \ - � CHECK If BILLING ADDRESS <br /> BUSINESS NAME \ \}�' ✓� f\\u d rt/l PHONE# EXT. <br /> HOME or MAILING ADDRESS /7 C C /� ` FAX# <br /> CITY � 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 HEALTFI 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 wor� 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 -'/�'�� -z;r ( DATC:,� <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER-LJ 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. <br /> TYPE OF SERVICE REQUESTED: AYM <br /> COMMENTS: e1%4e6 <br /> MAR 0 2102110..00 <br /> SAN JOAQUIN COU <br /> ENVIRONMENTAL 7V <br /> MALTH pt; <br /> ACCEPTED BY: . GY \ t EMPLOYEE#: DATE: <br /> ASSIGNED TO: 01-Lo EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: y��. 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 />