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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERV� A Q ZY <br /> OWNER/ PERATOR LJ <br /> CHECK If BILLING ADDRESS <br /> V• <br /> FACILITY NAME 4' i <br /> ) J q)")3 r 'A�` r] <br /> SITE ADDRESS l--, !� S -� <br /> Street Number Direction U t-41, 9f}S�tN�nFe�1 is jn Zi Code <br /> HME or MAILING ADDRESS (If Different from Site Address) <br /> 7 <br /> U e� �r Street Number 1 `� �I� / Street Name )r <br /> CITY S TE ZIP <br /> re c "2 10 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> n-,r) 2 �? 1 —q b <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR SC,( - <br /> /� <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME �l i I s PHONj=�� _ _E E] <br /> HOME or MAILING ADDRESS FAx#� <br /> CITY STA1:E ZIP /) <br /> 1 p� l/ <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 `ATE and FEDE aws. <br /> APPLICANT'S SIGNATURE: �-- DATE: _ 2 <br /> PROPERTY/BUSINESS OWNER L� 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 kt the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: I SC <br /> COMMENTS: 4* ? <br /> J <br /> Jnr ZO20 <br /> EN 0AQUI <br /> h p p Co At <br /> FNT <br /> ACCEPTED BY: l_I EMPLOYEE#: G� DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> J <br /> Date Service Completed (if already completed): SERVICE CODE: 1 PIE: �03 <br /> Fee Amount: "G' Amount Paid Payment Date ( 2_o <br /> Payment Type Invoice# Check# Received By: <br /> EHD 025 n (�(�� ) I SR FORM(Golden Rod) <br /> REVISEDSED 11/17/2003 <br />