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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> A F� Sg po 3ko <br /> . <br /> ..OWNER/OPERATOR i <br /> CHECK If BILLING ADDRES <br /> dUa <br /> FACIL NAME <br /> Siff ADDRESS / / t I rr G <br /> Street Number Direction /Stf.M'llrame7�6 CI Zip Code <br /> ME or MAILING ADDRESS to <br /> from Site Address) <br /> l(//moi((.•////11 d Streal Number Crn Street Name <br /> CITY STA E / • ZIP �� <br /> �o / L <br /> PHONE#1 EXT. APN# -LAND USE APPLICATION# <br /> (203 ) 17 / 13 .73 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If 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. / �f J� <br /> APPLICANT'S SIGNATURE: � ��Lj � � �( DATE: )C � — / p L o <br /> PROPERTY/BUSINESS OWNERI� OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> /f 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 t0 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: Uoa <br /> COMMENTS: <br /> ACCEPTED BY: ^ EMPLOYEE M �i , DATE: <br /> ASSIGNED TO: S , SV11L�� EMPLOYEEM ?) DATE: LV <br /> Date Service CompleYs already completed): SERVICE CODE: P/E: <br /> Fee AmountC� Z t Amount Paid /J�2 Payment Date -7'1 it I 2-0 <br /> Payment Type—VjInvoice# Check# Received By: <br /> 23-3- - <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />