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SAN JOAQUIN rO UNTY ENVIRONMENTAL HEALTH "EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> a, S 1�c;e y8l <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME 4 L <br /> p tz <br /> SITE ADDRESS 1�5151t/. bra /mac/- 153 6 <br /> Street Number Direction Stree a e it ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) �� <br /> Street N/umber 1 tr e-t Name <br /> CITY ST TE �-� IP; <br /> PH NE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK IT BILLING ADDRESS <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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �^��li `2YCDATE: <br /> PROPERTY/BUSINESS OWNER❑ /OPERATOR/ NAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AL'TI:O:�ZAT'ON :O RELEASE ',NFO— 'TION.; JJhen appiicabie, 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: l v 0 0 C-0 rJ S L4-L-1-47t-7 0 <br /> COMMENTS: <br /> Ca��e�4C 4 <br /> o. o e �`, s� , C- ' , <br /> " �� � �) �; ;�.:. .. 011 <br /> ACCEPTED BY: 0 <br /> LC v� C EMPLOYEE#: (031, <br /> 03 DATE: (Q <br /> ASSIGNED TO: ( s cN6 E EMPLOYEE#: I t LZ o DATE: s r o <br /> Date Service Completed (if already completed): SERVICE CODE: C,� PIE: �p <br /> Fee Amount: Amount Paid 2 2 Payment Date S 0 <br /> Payment Type �/ Invoice# Check# �s $ 5 Receive By: �— <br /> -HD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />