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SAN JOAQUifiCOUNTY ENVIRONMENTAL HEALIILDEPARTMENT <br />IP SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />ACCEPTED BY: <br />SERVICE REQUEST # <br />gazS <br />Y <br />EMPLOYEE #: <br />PHONE # <br />FAX# <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS <br />FAclurr NAMEyl n �fIr1 <br />Fee Amount: <br />� Tn e rncLyj A.U r� <br />l..+ <br />ZIP 9 S' <br />SITE ADDRESS <br />Invoice # <br />Check # <br />Received By: <br />Lo a <br />5a <br />S et Number <br />6ren rwn <br />Street Name <br />cityZi <br />Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1T <br />APN # <br />LAND USE APPLICATION # <br />04CR) <br />PHONE #2T <br />( <br />BOI,— S DISTRICT <br />LOCATION CODE <br />CONTRACTOR • F , / l <br />REQUESTOR <br />COMMENTS: <br />ACCEPTED BY: <br />CHECK if BILLING ADDRESSEIT <br />BUSINESS NAME "A <br />I U4 <br />Y <br />EMPLOYEE #: <br />PHONE # <br />FAX# <br />_ Exr. <br />6332— <br />HOME or MAILING ADDRESS <br />01��i^ r <br />ITY <br />k- <br />Fee Amount: <br />STATE �r <br />ZIP 9 S' <br />R G 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 or <br />activity will be billed to me or my business as identified on this form <br />na <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 JOAQU <br />COUNTY Ordinance Codes Standard TATE and FEDERAL laws. <br />APPLICANT'S SIGNA DATE: �� 9' 000PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER 13 OTHER AUTHORIZED AGENT (GG cp orr2 / <br />IfAPPLICANT 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 />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE. <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />bate Service Completed (if already completed): <br />SERVICE CODE: <br />P / E: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />