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SAN JOAQUIN C, JNTY ENVIRONMENTAL HEALTH DE. tiRTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> D06 rei 5900813 / 9 <br /> O NER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> err V CO2 r �� <br /> FACILITY NAMt L 4 e Do6 5 O U T <br /> SITE ADDRESS / eft <br /> �� <br /> ZbGU- Street Number Direction �/�`StrtName V� `1 City Zip Code <br /> HOME o/r�MAILING <br /> �JADDRESS (If Different from Site Address) <br /> O BO J 0 }ES (`a Street Number Street Name <br /> CITY ^/t��, STAB ZIP <br /> PHONE#1 l- EXT. APN# LAND t USE APPLICATION# <br /> (205) 6621 M61 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESSNAMEW <br /> /e o' a` G 0&^1LPHONE# 2_ /Q / EXT. <br /> H E or MAILING ADDRESS FAX# <br /> CITY 1,.C �j STATEf�4 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 <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: - ��i'�� 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 the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: M <br /> COMMENTS: O�C® <br /> S�QCT 2 5201 <br /> ,e/vv�KQUI <br /> HZ p pgENTq�Nry <br /> ACCEPTED BY: B a 11 W Q n EMPLOYEE M DATE: <br /> ASSIGNED TO: ✓ CL41 4— 1a-01!q EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: 0 / PIE: (o D3 <br /> Fee Amount: 1 a . 00 Amount Paid (�a Payment Date <br /> Payment Type VI GJ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />