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SAN JOAQUOOUNTY ENVIRONMENTAL HEALTH*ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> COLL TY cw)4o F4 OCZ 3 9 '5- <br /> OWNER/OPERATOR <br /> �� / ��'�1�5 / D � �� ���� ' — �� �CKI BILUNGADDRESS <br /> FACILITY NAME <br /> SITEADDRESS l U S A dE9JraO,9. <br /> Street Number Directla Strwt Narrw City Zip Code <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 /> l ) <br /> PHONE#2 EirT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR 0AG6E- <br /> CHECK if BILLING ADDRESS <br /> �s�PN <br /> BUSINESS NAME PHONE# T <br /> 19© - av <br /> HOME or MAILING ADDRESS FAX# <br /> o AGGi0 0 0► b - ria <br /> CITY ,r O D/ STATE 1* 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 FED L laws. / <br /> APPLICANT'S SIGNATURE: ! DATE: <br /> PROPERTY/BUSINESS OwxER❑ OPERATO AGER O A RIZED AGENT/ CEhv6 Fri 0� <br /> If APPLICANT is not the BILLING TY proof of authorization to sign is required a 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. ENT <br /> TYPE OF SERVICE REQUESTED: S ECE� <br /> COMENTS: <br /> L+ Gousv <br /> SAN��RpNME TM� <br /> H�UTH pEPAR <br /> ACCEPTED BY: EMPLOYEE#: 000 t <br /> DATE: <br /> ASSIGNED TO: (Aj EMPLOYEE#: 0044 <br /> DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1 Cl PIE: <br /> Fee Amount: Amount Paid? Payment Date S� <br /> Payment Type Invoice# Check# ` Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />