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SAN JOAQL.w COUNTY ENVIRONMENTAL HEAL I__ JEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> J 'L V "l✓ t <br /> SITE ADDRESS 1q Z 16ko,(\6 CO,�a ` S[OC 1� �� Q 5 ZQ? <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or(M/AAILING ADDRESS (If'Dii�fferrlen from Site Ad/�dfr,�ess) ��///1� <br /> 2_L'1 A t t� A l Y "V Street Number Street Name <br /> CITYG STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# tel! <br /> (-w <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> C <br /> t9 CHECK If BILLING ADDRESS <br /> BUSINESS NA E PHONE# ExT. <br /> C <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY STATE ZIP 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 ild that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE an DERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 42-2 S-lGl <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/si sessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the„�a U <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: vwj V WV H _ <br /> COMMENTS: O2 <br /> � RDNME ONN <br /> H�Ep�R M At <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: n�, �Ul EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed: SERVICE CODE: 0'n PIE: (PO <br /> Fee Amount: 1 Amount Pao /sa 00Payment Date20 <br /> Payment Type �t Invoice# Check# Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />