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SAN JOAQUIN --OUNTY ENVIRONMENTAL HEALTH Dr.. ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS <br /> Ll 2t ©V0 ��{k�I L&I <br /> FACILITY NAME /\I E \ o ) /CL�,�r CO .I <br /> SITE ADDRESS L� ,, <br /> � L(/�JC{ISI <br /> Street Number Direction Street Name cn .;ode <br /> HOME or FAILING ADDRIc§S (If QMe rent from Site Address) <br /> C� A LA <br /> Street Number I Street Name <br /> CITY STATEa ZIP 9 <br /> PHONE#1 E.T. APN# LAND USE APPLICATION# <br /> � �31cx� zb <br /> P ONE#2 EXT. BOS DISTRICT CAT ON CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REST <br /> CHECK If BILLING ADDRES <br /> Bus��Ir;sD AAAe(�1C� P N # Z7 l3 " v�4XT. <br /> NOME or MAILINGADDRESS FAX# <br /> CITY T� C /TrJ� STATE n 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 1 aftAa <br /> and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Sta ar , FEDERAL WS. <br /> APPLICANT'S SIGNATURE: ` DATE: 41- zl lz <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 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 thame time it is <br /> provided to me or my representative. A <br /> TYPE OF SERVICE REQUESTED: � <br /> COMMENTS: <br /> F QU <br /> y4C i�Fp N FN""14 <br /> ACCEPTED BY: rc ev o EMPLOYEE#: DATE: _ Z _ <br /> ASSIGNED TO: ``C w CA r EMPLOYEE#: DATE: Z — I`C) <br /> Date Service Completed (if already completed): SERVICE CODE: (p, P i E: I U 0 2 <br /> Fee Amount: ,G� D Amount Paid / J Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />