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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> . SERVICE REQUEST <br /> Type of siness or Pr erty FACILITY ID# SERVICE REQUEST# <br /> -2 <br /> OWNEO OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME /ybaA V <br /> --�/� <br /> SITE ADDRESS ;l3 y /' �/j ,nil l� ,9,/� / l Iil (�O�t 3 <br /> Street Number /Direction ( (Y Street Na /(/ /t .Ci Zio Code <br /> HOME Or MAILING AD RESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> J� <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORZ§A2 <br /> ( / CHECK If BILLING ADDRESS <br /> BUSINESS NAME �C?�D� u✓ PHONE# Exr. <br /> HOME Or MAILING ADDRESS FAX# <br /> c253� (ate ) 4�P r -613t-2- <br /> CITY STATE l ZIP <br /> E'1 <br /> BILLING ACKNOWLED EMENT: 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 /> COUiqY Ordinance Codes,Standards TATE and FEDERA 1 S. <br /> APPLICANT'S SIGNATURE: DATE: 7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGEN c I• � <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: <br /> COMMENTS: <br /> Jul- <br /> SAN <br /> ULSAN JOA()VIN COUNTY <br /> ENVIRONMENTAL <br /> l IEpLTH DEPARTMENT <br /> ACCEPTED BY: / EMPLOYEE#: DATE: 21 <br /> ASSIGNED TO: EMPLOYEE#: DATE: ' / <br /> Date Service Comple ed (if already completed): SERVICE CODE: P f E: <br /> Fee Amount: �-�Or. C77D I Amount Paid /� W Payment e ' Z( <br /> Payment Type Invoice# Check# \ \ tj Received By: � <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />