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t <br /> SAN JOAQIWOUNTY ENVIRONMENTAL HEALTI&PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME 7(11 <br /> SITE ADDRESS �ZJ &n Y <br /> Street Number Direction I Street Name city e <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT--7F OCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEST/OR Ale i I SAA 6; <br /> X a4'h/e C'%7 AlCHECK If BILLING ADDRESS <br /> BUSINESS NAMPHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> j'I Lp t-s t t<X77 f�i S f - (�%,�J► `t<�o�—,F�S 3 <br /> CITY l t'czSrz/I�L' 1 STATE /{j ZIPOSZ4 <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: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Ll/7 lfc.L'; <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: <br /> COMMENTS: <br /> 5✓��Rp M TM <br /> H�yn.{DEPAR <br /> ACCEPTED BY: EMPLOYEE#: DATE: Vo <br /> J <br /> ASSIGNED TO: C1 A-( 1 EMPLOYEE#: DATE: C� <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: a Amount Paid %3-75- D Payment Date <br /> Payment Type 15 Invoice# Check# q (o(3 y?6� Received By: <br /> EHD 48-02-025 L(� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />