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SAN JOA` COUNTY ENVIRONMENTAL HEAL ' DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID ty SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Cnecx if <br /> FAcIUTY NAME <br /> SITE ADDRESS <br /> Streal N mbar imlign s"et Naml <br /> HOME or MAILING ADDRESS (If Different from Site Address) f <br /> < c <br /> 11 <br /> Sit"t Number Str alill <br /> Clry STATE cil, zipff <br /> PHONE#1 Err. APN# LAND Use APPLICA <br /> PHONE#2 FxT, SOS DISTFACT LOCATION CODE <br /> I - 15 1 —13 <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR CHECK If 54.LiNg AoogesizL <br /> BUSINESS NAME c c PHONE ExT, <br /> HOME or MAILING ADDRESS FAx# <br /> CITY STATE zip <br /> BI"ING ACKN!QWLEDg1,MfN1: 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 /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: "I <br /> DATE- ("c" <br /> PROPERTY I BUSINESS OWNERO OPERATOR/MANAGER OTHER A%1TH0RlZtD AGINTEZ <br /> I Lrv! bcv; <br /> IfAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTJ1!2R1A11ON TO RELEASE INFORMAIIQN: When applicable,1,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 3OAQUIN 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 /> 7;:" <br /> TYPE OF SERVICE REQUESTED: L T- oei-7 1-7- Z/ <br /> 0 20r!Q <br /> COMMENTS: is -J <br /> L <br /> ACCEPTED BY: <br /> EMPLOYEE 2 ATE: <br /> ASSIGNED TO: EMPLOYEE DATE: 1 L C'­7 <br /> Date Service Completed (if alWady completed): SERVICE CODE: P/E:-2 <br /> Fee Amount: Amount paid <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48.02-026 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />