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SAN JOAOC _ _ COUNTY ENVIRONMENTAL HEAL1 . _ t)EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> DivC� <br /> OWNER / OPERATOR <br /> • � _ _ \ C ` l,'\ . ^ � � � r CHECK If BILLING ADDRESS <br /> FACILITY NAME (J V \ <br /> 5 iciS - 70C n <br /> s <br /> SITE ADDRESS (' 11 `� U C G 0070 e5 <br /> G <br /> WW AtreltNumber Direction � �` " �1" 1 V1 Stree�e Cit Zi Code <br /> HOME or MAILING ADD S (If Different fr m Site Add(ess <br /> Street Number �� I r Y) Street Name <br /> CITY STATE ZIP _ <br /> PHONE #1 EXT, APN # LAND USE APPLICATION # <br /> (2c 1 ) <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> ( � ' ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> QUESTOR , } <br /> 1 r ` r,r '1 laflcx ( <br /> �� � �/� , �I CHECK if BILLING ADDRESS <br /> B SLINESS NAME V \ 1 CT +9 I` \ I PHONE # EXT, <br /> z` _ j 5 l C01 <br /> HOME or MAILING ADDRESS FAX # <br /> CITY 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 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 SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL ws . h <br /> APPLICANT ' S SIGNATURE : Y DATE : <br /> PROPERTY / BUSINESS OWNER ❑ PERATOR / MANAGER ❑ THER 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 : <br /> COMMENTS : <br /> I lrt. Ud ,y9aQu � <br /> NT <br /> ACCEPTED BY: LACO EMPLOYEE # : qg ® DATE: 24 909eo <br /> ASSIGNED TO : EMPLOYEE # : DATE: f ee;d <br /> Date Service Completed ( if already completed) : SERVICE CODE : j5>- 3 PIE : i0Q , <br /> Fee Amount: ' ` Amount Paid GPayment Date ILA /zg 2 O2� <br /> Payment Type Invoice # Check # Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> REVISED 11 / 17/2003 <br />