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SAN JOAQ COUNTY ENVIRONMENTAL HEAL&EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE Rr ��,, <br /> REQUEST# <br /> 000 �[L4A— <br /> OWNER I OPERATOR <br /> e' _V- Zo kA e e CHECK If BILLING ADDRESS <br /> FACILITY NAME 1 �� C\ <br /> SITE ADDRESS ,G�✓1 V Jl_ �I����1�� <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATEZIP <br /> ON <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> 215-20�� <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CCHECK If BILLING ADDRESS <br /> BUSINESS NAME G`� ^_ 1 �\ _-� PHONE# 5--1f+ <br /> HOME or MAILING ADDRESSt�r�1 t/2 t� FAX# <br /> 1 Y' ( ) <br /> CITY —` j STATE /1n ZIP S-7C <br /> 0 <br /> BILLING vA IC rK�NOWLEDGEMENT: 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 laws. <br /> APPLICANT'S SIGNATURE: DATE: <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 at %a time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> S'gNJp,I ?41� <br /> FNVj QUW <br /> 06pp ��N� <br /> NT <br /> ACCEPTED BY: �I EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: l <br /> Date Service Completed (if already completed): SERVICE CODE: O PIE: W� <br /> Fee Amount: t Amount P ' ��-� Payment Date / <br /> Payment Type Invoice# Check# Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />