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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTH&ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPWTOR <br /> !! // CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> � 1 <br /> SITE ADDRESS�,/)/f s� �L✓�/� -!OA62�57 _ <br /> �"Street Number Direction Street Name Ci ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE*') ExT• APN# LAND USE APPLICATION# <br /> PHONE#Z W. BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REt3UJcSTOR 1477W.-* <br /> � <br /> E CHECK if BILLING ADDRES <br /> BUS SS E PHONE# ' <br /> HOME or MAILIN ADDRESS FAx# <br /> CI G r c G) 1D/ <br /> CITYA—P 44eleW2 41;&1v?4Q2&A ef-A -1 :J <br /> STATE ZIP �yj <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 and FEDE laws. / <br /> APPLICANT'S SIGNATURE: DATE: / / �} <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Ryl��GdY/ fi�s//t 01?1 <br /> If APPLICANT is not the BILLING PART} 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: PAY M <br /> COMMENTS: <br /> Jul- 16 21 <br /> 1, <br /> SAN JOAQUIN COUNTY <br /> EN'llf ENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: �� DATE: <br /> Date Service Completed (if already completed): SERVIC CODE: PIE: (1 <br /> Fee Amount: Amount Paid CJ Payment ate <br /> Payment Type ✓" Invoice# Check# -2— Received By: tV <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />