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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0 1110 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME A 6 <br /> SITE ADDRESS' — <br /> � IcaS�Ct 6, <br /> [` Jl <br /> Street Number Direction Street Name Ci ZID Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Err. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORCLQ S$ <br /> Lt G CHECK If BILLING ADDRESS <br /> 7, c/ ,, <br /> BUSINESS NAME �.,��^ ���� PHONE# � t / �3 <br /> HOME or MAILING ADDRESS -lJ ,` FAx# J [ <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 or <br /> 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: J,,La DATE: -,n / U <br /> PROPERTY/BUSINESS OWNER P RAC <br /> O <br /> TO /NIANAGER ❑ OTHER AUTHORIZED AGENT❑ `a' <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 Iad�aj(he same time it is <br /> I%\ 'r C <br /> provided to me or my representative. P 1` c <br /> TYPE OF SERVICE REQUESTED: - G� <br /> COMMENTS: . p,PR <br /> 0,-y S SAN 3ONQ\3%tAcouto <br /> a j <br /> !Cc c �/ <br /> ACCEPTED BY: G EMPLOYEE#: Dp: <br /> ASSIGNED TO: EMPLOYEE#: vil1 v DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I <br /> ZOsPaFee Amount: Amount Paid0 Payment Date 'f(710-5— <br /> Payment <br /> yment Type ,/ Invoice# Check# -7 Received By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />