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SAN JOAQUI OUNTY ENVIRONMENTAL HEALT�EPARTMENT <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 /> SITE ADDRESS 3?X— 5 CWI� <br /> Street Number Direction 1 Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number 4.71 <br /> CITY STATE]rDJ[%SV4tPL JL <br /> PHONE#1 XT. APN# LAND P <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR V <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> -'dL G�� ( ) ` )'F - 20`! '�Gt <br /> HOME or MAILING ADDR SFAx <br /> CITY 1 STATE ZIP <br /> BILLING ACKNO EDGEMENT: 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,St ands, TE and FERE laws. <br /> APPLICANT'S SIGNATURE: DATE: a <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR ANAGER ❑ OTHER AUTHORIZED AGENT LJ}� �fir+ �r <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required//l/// Tit e <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby alporize the release of any and all results, geotechnical data and/or enviro Riinformation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available a a <br /> provided to me or my representative. VVIDT <br /> JLJ.Z� x JL <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 'PIKKIVRECEIVED <br /> EXPIRED AuG 7 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: 6 I✓ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: D <br /> Fee Amount: aD Amount Paid L T Paymckt Date -Z <br /> Payment Type Invoice# Check# ReceivedBy: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />