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SAN JOAQUI*OUNTY ENVIRONMENTAL HEALTAPARTMENT <br /> • SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR ghet4u[ CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS� (�A-«-�LOo �'�oG�Clpv�1Tq!5-a O 5 <br /> Street Number Direction freet ame Ci Zi 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 /> Q104) y66 —x`51(. <br /> PHONE R Err. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME T\_ , u-�v \ ��, a' #1���— ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY CSS STATE C(1 . ZIP �S 1 <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,Standar-&Standar—& STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: C ( 1 ,O'YL DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT a <br /> IfAPPLICANT is not the B/LmNG 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: ( S j( f`j PAY Ep <br /> COMMENTS: O e1o1� <br /> JIJL 2 L 1 <br /> SAN JO Qum COUNN <br /> HEAD-TM DEMENTA <br /> PAR�ENT <br /> ACCEPTED BY: V��\i i EMPLOYEE M Q 3 L/ DATE: Z tf/ <br /> ASSIGNED TO: (,V U ti EMPLOYEE MDATE: --7 _) I j <br /> Date Service Completed (if already completed): SERVICE CODE: j PIE: 'Z C' � <br /> Fee Amount: ?�In(zJ Amount Paid -43`(e DPayment Date 7 —ko <br /> Payment Type ✓ Invoice# Check# al 2-7 p Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />