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SAN JOAQUIIv COUNTY ENVIRONMENTAL HEAL'I;_ . EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business`or Property FACILITY ID# SERVICE REQUEST# <br /> OWN R i OPER TOR ) <br /> ` CHECK If BILLING ADDRESSO <br /> MA <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 7 5 � r�►Iq <br /> Street Number Direction Street Name Cit Zi Code <br /> Ho M or MAILING ADDRESS (If Di &ent from Site4dress) <br /> e Street Number Street Name <br /> CITY C � /�1� � �� � � STATE ZIP <br /> PHONE#1 (-EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR r <br /> Uu CHECK if BILLING ADDRESS <br /> BUSINESS NAMEI�I I PHONE# ExT. <br /> v <br /> HOME Or MAILING ADDRESSZo U'l-'o ft -00/'(x 5j- <br /> (AX# ) <br /> CITY A0 - V\ STATECA ZIP 15 2D 3 <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 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 I( S. <br /> APPLICANT'S SIGNATURE: �/( DATE: 2,L=) <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 ai.the same time it is <br /> provided to me or my representative. I AY <br /> TYPE OF SERVICE REQUESTED: CF <br /> COMMENTS: �QR <br /> s'9"✓o 0 y ?020 <br /> COIJ <br /> ARTMFkT <br /> ACCEPTED BY: C n�1 EMPLOYEE M DATE: 3 �� <br /> ASSIGNED TO: S ,ZG�\`rC�� Z- EMPLOYEE M DATE: 3`L{ 'Zv <br /> Date Service Completed (If already completed): SERVICE CODE: V PIE: <br /> u2) <br /> Fee Amount: ---� Amount Pald Payment Date <br /> Payment Type &116 Invoice# Check# Received By: <br /> ­ v <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />