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� Y <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S R N�- I F) � <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> \ ACL, \ G1 <br /> FACILITY NAME C15 c <br /> SITE ADDRESS 2 t+ Z <br /> Street Number Directiontreat Name Cit es ai od <br /> HOME or MAILING <br /> ADDRESS (If Different from Site Address) /3 t 1 ti 54 L <br /> I Ct L' -2 o �h Sf Street Number Street Name <br /> 7 <br /> CITY STATE zip _ <br /> rJVv-\ C Pc15 2C'' <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME /1 PHONE# (-/ <br /> EXT. <br /> FL 2 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY n STATE zip � <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of salne, <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 /> 1 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: ��nc' DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTIE UTHORIZEDAGENT❑ <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: ��vl� I R �N <br /> COMMENTS: J <br /> J(j� <br /> �5 <br /> SqH�Oq 2420 <br /> ENV/ QU/N <br /> N�CTyO A �N7y <br /> ACCEPTED BY: CA LA I EMPLOYEE#: DATE: <br /> ASSIGNED TO: V ( r r EMPLOYEE#: DATE: I .r <br /> Date Service Completed (if already completed): SERVICE CODE: / P E: <br /> Fee Amount: : �' Amount Paid � Payment Date 2 O <br /> Payment Type Invoice# Check# Received By: rlu <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />