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0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR _ <br /> \Q� \ CHECK if BILLING ADDRESS <br /> FACILITY NAME v <br /> 'r c2J`c1 �. 5� <br /> SITE ADDRESS �Ul W \/��e ,��� - ,A0� s 33� <br /> 7 �(Y�C�C\�-f'C� <br /> Street Number Direction Street Name cityZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# <br /> LAND USE APPLICATION# <br /> PHONIER EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 6 ebb CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> \ GJ rc,C-Voc'-:�J —4- n(_ y ► (� 33 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY ,(nG�� �e C ti STATE CC' ZIP US-- <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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: QA� DATE: C `D <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT CEJ` <br /> If APPLICANT is noCe 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 /> PAYMENT <br /> TYPE OF SERVICE REQUESTED: 4- RLUEIVEE3 <br /> COMMENTS: <br /> JUN 9 2005 <br /> SAENVIRONMENTAL OAGUIN O � <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: o 1 D - vr EMPLOYEE#: O DATE: ( n �S <br /> ASSIGNED TO: l J 1 `^'V EMPLOYEE#: X ATE: l <br /> � '�1 X50 <br /> Date Service Completed (if already completed): SERVICE CODE: C' PIE: <br /> Fee Amount: r Amount Paid --jc, Payment Date �, O <br /> Payment Type Invoice# Check# 7 Received By: <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />