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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# —SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> i <br /> CDIDHECK If BILLING ADDRESS <br /> C r , C. <br /> FACILITY NAME <br /> f <br /> SITE ADDRESS 3y� <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#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) 1'J t ' OffV - 5j'n <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> 4Y\C— (gtJa) <br /> HOME or MAILING ADDRESS FAX# �2 <br /> 0 C (t, ) t L J <br /> CITY Sa i G STATE Q Il ZIP C 51f6l <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 or <br /> 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: C;. DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT <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: Li's PAYMENT <br /> COMMENTS: i " <br /> FEB 11 200$ <br /> ,,'h p I Gr 1,e,0'1 -e v? f V fyl;tj SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> n HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: C DATE: <br /> ASSIGNED TO: EMPLOYEE#: ✓X1JJ �IJJ J DATE: <br /> Date Service Completed (if already comp) ed): SERVICE CODE: <br /> Fee Amount: Amount Paid �� C' Payme t Date �r ll <br /> Payment Type Invoice# Check# � � Received By: <br /> EHD 48-02-025 SR FORM(Golden F <br /> REVISED 11/17/2003 <br />