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t <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE RE UEST# <br /> 7 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS CG�e 1'�0.• ����� 1.C�1�M� IS Z 3 <br /> Street Number Direction Street Name Ci ` Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> RVICE REQUESTOR <br /> REQUEST( <br /> CHECK If BILLING ADDRESS <br /> BUSINESS P `V`���-��LOVI PHONE# EXT. <br /> HOME or M, FAx# <br /> S2 �k"� c ) <br /> CITY STATE Zip <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: W O'r )v� - T �+ l <br /> COMMENTS: SeCVNLJZ -CA-°" 5P--A k t VIS G.Y� U` V\,.%hSp e.C.�& \Q Y� h V�kf <br /> �Vc,& `��w-Q ©� �,�y (47L <br /> ACCEPTED BY: EMPLOYEE#: a 00 6 DATE: q `7 -) <br /> ASSIGNED TO: Ms <br /> -k- EMPLOYEE#: 1600 DATE: 11.7 t)-3 <br /> Date Service Completed (if already completed): C1- 1�� 1 2 SERVICE CODE: 0` P 1 E: A �p <br /> Fee Amount: Amount Paid / Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 /�� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 (9? <br />