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SAN JOAQUIN COUNT ENVIR <br /> ONMENTAL HEALTH D PAUL <br /> ICWWQUEST <br /> Type of Business or Property � , , FACILITY ID# <br /> SERVICE REQUEST# <br /> j tit <br /> TV <br /> OWNER I OPERATOR ` CHECK if BILLING ADDRE S <br /> FACIUrr NAME -- <br /> Q � <br /> SITE ADDRESS <br /> Ci ` <br /> -Street Number Direction Street Name rip Code` <br /> HOME Or MAILING ADDRESS (If Different from Site Address) "As 6-1 <br /> Street Number Street Name <br /> STATE ZIP <br /> CITY <br /> C-Ac� X14538 <br /> PHONE#'I <br /> Ems• APN# LAND USE APPLICATION# <br /> , <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS® <br /> BUSINESS NAME PHONE# �.��\ <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE Q�y_p ZIP <br /> �e <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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER E3 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Is <br /> IfAPPLICI4NT is not the$ILLINGPARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUINCOUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> � 1 <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> SEP 2 4 Zoo$ <br /> SAN JOAOUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEP ED BY EMPLOYEEwww <br /> #: <br /> EMPLOYEE.. <br /> ASSIGNED TO <br /> Date Sernce Completed (If already complet ): <br /> SERVICE CODE: <br /> JV <br /> F <br /> Fee Amount :' Amount Paid <br /> yment, ate <br /> 2 <br /> Payment Type _ ;,Invoice# Check#; Received By::\� <br /> EHD 48-02-025 <br /> s SR FORM(Gold( Rod <br /> � � r r <br /> REVtSED <br /> _ .�3p <br />