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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# 0-SERVICE REQUEST# <br /> A Q &�l � JR�yV 6 ��3 I <br /> OWNER/OPE T R <br /> L� e 1 (}� CHECK if BILLING ADDRESS E] <br /> FACILITY NAME <br /> 04-1, <br /> f���'(�/`A �,f�� <br /> SITE ADDRESS <br /> r1 l/ <br /> V treat Numb Direction treat Name city Zip Code <br /> HOME or M%INGADDRESS (If Different from Site Address) <br /> ' Street Number Street Name <br /> C� a STATE Zip <br /> v p, b T J <br /> PHONE#f EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVI R <br /> REQUESTOR <br /> �Ao--1. I ,A (� CHECK if BILLING ADDRESS <br /> BUSINESS NAME^ n�nf/` I,JJ J� PHONE# Ili �1 Exr. <br /> HOME or MAILING ADDRESS FAX# <br /> C l�0 it>� ( ) <br /> CITY SADL K-fa 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. r,, <br /> APPLICANT'S SIGNATURE: DATE: `'� <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: f 1 `l.� con S�( � r <br /> COMMENTS: VCLJ <br /> ?020 <br /> NJ T I RONM()AQu1N <br /> SALE""r T1' <br /> H N pEpART <br /> MINT <br /> ACCEPTED BY: 1AAEMPLOYEE#: ? DATE: 2 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P1 E: w3 <br /> 3 <br /> Fee Amount: Amount Paid - Payment Date SCJ <br /> Payment Type i h �� Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />