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SAN JOAQUIN WNTY ENVIRONMENTAL HEALTH IOARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> U S'/ 11 ova <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> sIT RN $ V,0aeei�c <br /> Street Number Direction C C <br /> HOME or MAILING ADDRESS (If Dffferent from Site Address) nw VA. <br /> Street Number S 1��1 i,r I T <br /> CITY STATE ZIPIFI ' D <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# 44AR 16 15 <br /> ('70q) f�39-6-Cd 4 SAN JOAQUI <br /> PHONE#2 Exr• BOS DISTRICT N L. <br /> ( ) PA RN Ems. <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> ^A CHECK if BILLING ADDRESS <br /> BUSINESS NAME 'f✓ PHONE# Err. <br /> D /!7 &i W i (11/4.) o? <br /> HOME or AILING RESS (?1 ) 9X4- 111,7 <br /> o to® )e <br /> CITY FT/ STATE 64 ZIP 9S7/ <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 app ' I d that the work be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar TE and F `DE laws. <br /> APPLICANT'S SIGNATURE. DATE: 3 t 2Z (S <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required ftte <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: c^ / �,> �p <br /> COMMENTS: <br /> W 1721 <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already c pieted): SERVICE CODE: FL' P 1 E: <br /> Fee Amount: Amount Pa c�b Z2) Payment Date 3 �6 e,,5 <br /> CU Payment Type Invoice# Check# l j�53 Rec ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />