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SAN JOAQUII'OUNTY ENVIRONMENTAL HEALTH*ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUES # <br /> 0 .0 Ij1 O <br /> OWNER/OPERATOR 'k, <� CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME - T <br /> FIL/I /� J <br /> SITE ADDRESS ®O!O 9536 6 <br /> Street Number Direction V treet Name Ci Zf Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) bcol 7t SO7/ <br /> �0 SW umber Street Name <br /> CITY v / / / V+ I TATE ZIP I <br /> PHONE#1 r t' L E"T• APN# LAND USE APPLICATION# f y J <br /> ( ) <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> D/ e U CHECK If BILLING ADDRESS <br /> BUSINESS NAME G,r�2y C PHONE/ # Sas 9/G d EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> 13`701 5• 1 � � (-3l0 I S3�-sy�y <br /> CITY STATE ZIP q o 2 <br /> `7 <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. / g- <br /> APPLICANT'S SIGNATURE: & if- . DATE:_�C�/0 li <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <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. <br /> TYPE OF SERVICE REQUESTED: � �) <br /> COMMENTS: C V le l��J/I L}s <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: P 1 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 />