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SAN JOAQUFWUNTY EWMONWNTAL HEALTH OARTWNT <br /> SERVICE REQUEST <br /> Type of Businen or Property FAC LffY ID# SERVICE REQIJEST <br /> I I <br /> OMER I OPERATOR CHECK N BILUNG ADDRESS <br /> FACILITY NAME <br /> SITE AmREss <br /> lc�-80..t Number r NAM2 an gqg2 <br /> HOME or Mum ADDREss (if DWerent from Sft Addfew) Stmet Number Sbeet Nano <br /> CITY STATE ZIP <br /> PHONE#1 T PI# D USE APPLICATION <br /> (:5o) --6 2 <br /> L-j�. <br /> P #2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR ff <br /> OAkAA— <br /> Ev. <br /> BusiuEss NAME PHOIffi# <br /> HOME orE <br /> MAILING,!A FAX# <br /> I -_ _?fff 11 ( <br /> Cl e-72- - STATE ZIP <br /> 'e .222M -7 <br /> B1NG ACKNQWLEDGEMEENT: 1, 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 /> CouNw Ordinance Codes,Standards and FED TATE <br /> 1, :rIWS� -7 <br /> PUC T'S SIGNATURE: DATE: <br /> PROPERTY/BusiNEss owNFx 13 OPERATORS MANAGER OTHm AuTnoitizED AGENT <br /> IfApnicANT is not the BILLING PAR.Ty proof of authorkadon to sign Is required Title <br /> AUTO TION IQ REI&M 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 ftaumm: <br /> COMMENTS: <br /> ACCEPTED BY: Est pLoYEE#: DATE: <br /> AssiGmED To: EMILOYEE#: DATE: <br /> Data Service Completed (W already completed): ZVICECODE: PIE: <br /> Fee Amount Amount Paid Pay nt to <br /> Payment Type Invoke# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />