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t SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <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 �� �,�, r'rc�clt Ca r"�Q 9 s z31 <br /> Street Number Direction Street Name city 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#2 EXT. BOS DISTRICT LOCATION CODE <br /> 9 C <br /> M REQUESTOR <br /> REQUESTOR w` Se��� <br /> i CHECK If BILLING ADDRESS <br /> d VLSQ�C�,�U✓�. <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING I FAX# <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, 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: �j � \�� C <br /> COMMENTS: Sc�:,C�2 C�veSy� Tp Zv�S�eC� O.x� 11h��S �, , l��✓ �t)Vh�pt.r <br /> �tO c et\,j QM5 Vojjt! (6 0,� O W ve�,_ Cesta a rr a ^; S t� �o � Q V\,- <br /> ACCEPTED BY: EMPLOYEE#: Ckoo C) DATE: <br /> ASSIGNED TO: ^A o EMPLOYEE#: 9 C)O(`� DATE:'`/'!I t <br /> Date Service Completed (if already completed): „ ' 1 SERVICE CODE: ©O1 P 1 E: 4 71 <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 <br />