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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE,IEQUEST# <br /> l n JVV11 dQ <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 1AUe <br /> Street Number Direction Street Name City Zip Code <br /> HOME or <br /> rr7MAILING ADDRESS (If Different from Site Address) <br /> (-C, <br /> fCA�N,� <br /> L / Street Number Street me <br /> CITY STATE ZIP_-Wei <br /> 1. S <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> VeCI II-C. �S f CS O <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORL Gl <) Gly c�,f CHECK if BILLING ADDRESS <br /> 1 Gt� <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: Cy <br /> DATE: vim`v w � � <br /> PROPERTY/BUSINESS OWNEROSY OPERATOR/MANA ER ❑ OTHER AUTHORIZF,D 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 ate same time it is <br /> provided to Ine or my representative. , <br /> TYPE OF SERVICE REQUESTED: I JPWCFS <br /> COMMENTS: <br /> Y 1 <br /> &WJ04QU <br /> 5 ftsf <br /> ?420 <br /> l 24c m l r6nc �f a ti-oo co m <br /> 11&4d.-r11/RoH IV ou <br /> CEPA M NT <br /> ACCEPTED BY: / ^ �� EMPLOYEE#: DATE: <br /> ASSIGNED TO: U \\\ EMPLOYEE#: DATE: / V <br /> Date ServicCompleted (if already completed): SERVICE CODE: r—) PIE: D , <br /> Fee Amou t Amount Paid Payment Date r�-, f �Zc) <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />