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SAN JOAQ*COUNTY ENVIRONMENTAL HEALWEPARTMENT <br /> SERVICE REQUEST <br /> Type of Busin ss or Property FACILITY ID# SERVICE REQUEST# <br /> :t <br /> OWNER/OPERATOR //// <br /> G1J CHECK If BILLINGADDRESS� <br /> FACILITY NAME � V� I'��vGG c� <br /> SITE ADDRESS �) �!✓ ��/ �lU �� �� <br /> Street Number Direction 7v,,n Cit Zi Code <br /> HOME or MAI N/G ADDRESS If Different from Site Add ess) 216 ` r�� '(-� I 7r <br /> CStreet Number LL treat Name <br /> CITY � .� ST � ZIP <br /> P�q ) 2� �22� EXT APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING AOORESS® <br /> BUSINESS NAME PHONE# EXT' <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY 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 <br /> and <br /> FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 441-40Jw6k �V! DATE: b ! <br /> PROPERTY/BUSINESS OWNER 11 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. J <br /> TYPE OF SERVICE REQUESTED: j � <br /> COMMENTS: <br /> f G,l t5 ,ire (-�C C,,_ C,yrs %, <br /> ,-. L,1 l <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> t <br /> ASSIGNED TO: EMPLOYEE#: :3:T7'3 DATE: C.l'O _rL <br /> Date Service Completed (ifalreadycompleted): SERVICE CODE: I(?, I 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 />