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SAN JOAQP COUNTY ENVIRONMENTAL HEALTL EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> , - G f q() <br /> OWNER/OPERATOR e—d�N°`� j <br /> (J C. CHECK If BILLING ADDRESS <br /> FACILITY NAME CS'Ce G V 6-'t t W 0-1 i <br /> SITE ADDRESS �US'��l <br /> / Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'I EXT• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR '^ I (V� 'y' <br /> CHECK if BILLING ADDRES ' <br /> BUSINESS NAME PHO�N�E# <br /> HOME or MAILING ADDRESS FAX# / <br /> CITY STATE 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 <br /> andFEDERAL laws. <br /> APPLICANT'S SIGNATURE: C!j DATE: <br /> PROPERTY/BusiNESs OWNERpr OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL1cANT is not the BILLING PAR 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: u,ST \ J �4 <br /> COMMENTS: JA <br /> NQ4 <br /> Av2013kNQJINCOON <br /> S'NEAriq=i)EpMEN <br /> ACCEPTED BY: l EMPLOYEE#:C-2-6 DATE: P It <br /> ASSIGNED TO: 1LG `�Q ) EMPLOYEE#: D DATE: 1 3 <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: �. Amount Paid Payment Date I <br /> Payment Typeqi S Invoice# Check# VPReceived By: <br /> ;-"7 6, <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />