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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> a O'�) � 1 S�( �I `4U <br /> OWNER/OPERATOR <br /> 'INC <br /> C CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS Co <br /> r` G Y�.I Ci S� SjLkp j ' S pZO,Z , <br /> 1 0"i Street Number (rection ' treet Name CI t Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> <I q 25 yLy-A e:ffi Street Number Street Name <br /> CITY STATE ZIP <br /> 45 4 6 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) 6 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PH NE# ExT. <br /> t C 5) <br /> HOME or MAILING ADDRESS FAX# <br /> CITY . V STATE ZIP q4,34 f . <br /> BILLING ACKNOWLEDGEMENT: , 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, STAT no FEDE T <br /> L laws. <br /> APPLICANT'S SIGNATURE: 10V DATE: �1� o'z 1 I, 2c^L i� <br /> PROPERTY/BUSINESS OWNER RAT /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. iQ <br /> TYPE OF SERVICE REQUESTED: R <br /> S ( EC <br /> COMMENTS: JUN <br /> ry <br /> of <br /> JOAQUIN COUNTY <br /> TMDc ARTMENT <br /> ACCEPTED BY: LA r EMPLOYEE#: l( U DATE: ' Z� <br /> ASSIGNED TO: EMPLOYEE#: L� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: -�X� <br /> Fee Amount: U� Amount Paid Payment Date <br /> II <br /> Payment TypeJ` Invoice# ?� 1- Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> P oiu100 <br />