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SAN JOAQ OUNTY ENVIRONMENTAL HEALTPARTMENT <br /> fi SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> s s � c vz.5 got (o toza- Gfto,434 43 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME _ <br /> SITE ADDRESS ) S'�l � C12.11�i1� VZV. CL S(?C�51 CiSj(Ei�j <br /> Street Number Direction Street Name city zip 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# LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# _ EXT. <br /> 99/- <br /> HOME Or MAILING ADDRESS FAx# <br /> furNit (40,-) a) 3-too, 3 <br /> CITY c 5�� 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 <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. / ,/f <br /> APPLICANT'S SIGNATURE: D�� DATE:: l 2 `US <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT lig <br /> If APPLICANT 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. ENT <br /> TYPE OF SERVICE REQUESTED: (,(S T AM790 rl- RE�EIV <br /> COMMENTS: n i 1 r 1 Q 2005 <br /> N1j13 NTY <br /> SAN JOAOLlm RENT <br /> HATH DEPARTM <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: ^�� EMPLOYEE#: 9;49 3 DATE: 0//0/6,5- <br /> Date <br /> /O ds"Date Service Completed (if already completed): SERVICE CODE: 9cf P 1 E: 2 3 O ff' <br /> Fee Amount: Amount Amount Paid �� J p Payment Date Q r p p,S' <br /> Payment Type Invoice# Check# � o Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />