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tbm <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property ` I�F�q # SPICKS T# <br /> I�\}U ) U l <br /> OWNER/OPERATOR [SK <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> V <br /> SITE ADDRESS �Z/{o <br /> L�d `� 1-9 <br /> Street Number Direction �v iStreet Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> r <br /> Street Number Street Name <br /> CITY STATE Z <br /> CL--Lo V\ Z <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (�'-0/3) � 4 L 11 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> M Gleam O <br /> HOME or MAILING ADDRESS FAX# <br /> CITY v- STATE ZIP �^ <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPAR'T'MENT 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: DATE: <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER Er 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, 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/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 Ine or my representative. P <br /> TYPE OF SERVICE REQUESTED: A RAO A k( <br /> COMMENTS: <br /> SAV JOA Q U <br /> 141 FP FNo n' <br /> _ ARTMENT <br /> ACCEPTED BY: EMPLOYEE#: L DATE: /r <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I /1 PIE: I(y6 l � <br /> Fee Amount: ( C� Amount Paid l,- Payment Date -3 y2-4 2 <br /> PaymentType'V Dt&Llt In-voice# Check# Received By: <br /> EHD 48-02-025 (/l/t v� I D D D eZ-S G SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />