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1 <br /> t SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS <br /> / tit � �v►e.. . <br /> FACILITY NAME / / <br /> t t' rl <br /> SITE ADDRESS �*—� ` *f �� n R ,/I l 1 ej4-- <br /> Street/Number Diir6e°ction Street Name City Zi2 Code <br /> HOME or MAILING ADDRESS p(if Different from Site Address) d <br /> 7- t, `� Street Number Street Name <br /> CITY /"I �, t STATE ZIP <br /> PHONE#1 t Exr' APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR IL C, IN L' Z CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# �' <br /> IL,(/�0.�' iS - �rytcd S Co - Z( 305--9 ( CS() <br /> HOME or MAILING ADDRESS FAX# <br /> /3-70 / -s �/n-t �+ (3cv ) s-2-7-7.�f$`f <br /> CITY STATE � ZI <br /> & C _ yL P Co 2G Q <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: DATE: �S/d S <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT -,S t�Q e k(V 1.5 6V <br /> IfAPPLiCANT is not the BILLING PARTY,proof of authorization to sign is required 1 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. n Jt.� <br /> TYPE OF SERVICE REQUESTED: EV t ipV1� Cs t'� U V9 C rc—C(L— <br /> COMMENTS: C� S <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />