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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT EPART ENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> S a s CL- o <br /> SITE ADDRESS <br /> 3' Street Number Din %Lqpt Name2 C de <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• N# LAND USE APPLICATION <br /> { ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> { ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQuesTOR \ <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME- C ` ®,, �,, PHONE# Ext. <br /> HOME or MAILING ADDRESS FAX# <br /> 1\?-gaC> ®ra C'�v��Ca 2 r` (G1--) (at I <br /> CITY P. e.d\ ® C o o v STATE ZIP q S-7 q � <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,S ;7/ERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> DATE: C�o 2-2-- C)9 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT 1Z <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: t0 ,F <br /> COMMENTS: �iE,CaEI ti_._ <br /> JUN <br /> SAN JOAO""V,R F <br /> ENVIROR I t,"� <br /> HEALTH UN II�-; <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid t Payment Date <br /> Payment Type Invoice Check# 7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />