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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTA6ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> e 0S �1 g <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME WAX <br /> AX ' c�J <br /> SITE ADDRESS Iv 1 <br /> 31411 Street Number I Direction Name V C/ •Zi COde� <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number treet Nam <br /> CITY - STATE ZIP n 1 <br /> 21 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> t-Q ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> $3- 44' 6 <br /> HOME or MAILING ADDRESS FAX# <br /> IA-11 k dvgxot ) <br /> CITY STATE zip <br /> C. <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,STA n EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: j 2 <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, .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 me or my representative. a <br /> `'N� <br /> TYPE OF SERVICE REQUESTED: G <br /> COMMENTS: <br /> F�8 L <br /> COVNN <br /> SPN 30 P"CNM6 ii NZ <br /> ACCEPTED BY: C-, �f EMPLOYEE M DATE: <br /> � <br /> ASSIGNED TO: /�ox EMPLOYEE <br /> `��w EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ���� P I E: <br /> Fee Amount: D v Amount Paid 4 (S- Z_ Payment Date <br /> Payment Type Invoice# Check# Received y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />