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SAN JOAQUIN _ -)UNTY ENVIRONMENTAL HEALTH L—?ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> :Ls 0 i <br /> OWNER/OPERATOR / <br /> 0 Iff a I^' CHECK if BILLING ADDRESSO <br /> FACILITY NAME I <br /> SITE ADDRESS <br /> t7eet Number Dlr !on Street Name V Zin Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) ////��((//l/11 /p` <br /> )—Wet umber C ` reet Name "" <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> /l �t , /� �/� CHECK If BILLING ADDRESS <br /> SINESS NAME V (/( ,1(,1� J (/l PHONE# ExT' <br /> HOME or MAILING ADDRESS FAX# <br /> CITY / $TAE ZIP <br /> BILLING ACKN`OWLEDGEMENT: 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 S�l l� yIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. �CF�'t <br /> APPLICANT'S SIGNATURE: u� �yl Qqq� DATE: .14A, _ c—NFQ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ S�y <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required l�I/jROC <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the proper ;;��� ((�� V- <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site asb�nt <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It rs <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> 0� ivy e - Jn I <br /> ACCEPTED BY: I In LA(-oi EMPLOYEE#: DATE: <br /> ASSIGNED TO: l• EMPLOYEE#: 0/g� L DATE: i yl u <br /> Date Service Completed (if already completed): SERVICE CODE: v PIE: �;3 <br /> Fee Amoun : 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 />