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1 <br /> SAN JOAQUIN&LINTY ENVIRONMENTAL HEALT-MI wdlhPPARTMENT <br /> SERVICE REQUEST <br /> ype of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C c' 0e3 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS Ck"CW <br /> �� ► l n �` t-OCL;_ <br /> Street Number I Direction The Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) {, <br /> t� Atreet Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#T EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> /dV c6n /T_ cto CHECK if BILLING ADDRESS <br /> BUSINESS NAME ( PHONE /l, I —EXT* <br /> Qdn 1 U <br /> HOME or MAILING ADDRESS FAX# <br /> ( 1) - Co <br /> CITY J 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 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,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 4 \VM W k&J DATE: 6Q± u ikk <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT'NL fiP n o y� "yjj <br /> IfAPPLicANT 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: P CEIVE� <br /> COMMENTS: Oct <br /> IOAQUIN coo,- <br /> sDEPENS <br /> ACCEPTED BY: EMPLOYEE#: 3 DATE: <br /> ASSIGNED TO: EMPLOYEE#: �Z DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Iq PIE: . u <br /> Fee Amount: � 1^` Amount Paid 37J1,�� Paymen Date 11) ' <br /> Payment Type Invoice# Check# �$ Received By: <br /> EHD 48-02-025 SR FORM{Golden Rod) <br /> REVISED 11/17/2003 <br />