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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 9 5d-:39a <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY N <br /> SITE ADDRESS l\\ ,��Lj�� <br /> Sire et Number D on C- et Na e `� �eae <br /> HOME Or MAIIJNG-A DORES (If Different from Sitg,6kdress <br /> StrMNvmber V4fV&etName <br /> 7 TATE ZIP 7 <br /> J <br /> P{{H��O�N-�#}1 EXT' APN# / LAND U E APPLICATION# <br /> PHONE 2 EXT' / BO$DISTRICT LOCATION CODE <br /> �� C. ( / <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME <br /> PHONE# EXT. <br /> HOME or MAILING ADDRESS FAx# <br /> 1 ) <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 or <br /> 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 Colles,Sian a s, STATE and FEDE L lal [.�. <br /> APPLICANT'S SIGNATURE ,p�� DATE: ! —30^d <br /> PROPERTY/HUS INESs OWNER❑ OPF-BATOR/MANAGER OTNER AUTHORIZED AGENT❑ <br /> /f APPLICANT iS t the BILLING PARTY Proof of autGorilation 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 /> - rvr�- <br /> TYPE OF SERVICE REQUESTED: (?� ,N_C tt'1— A--7Z v/J Cl /� "",,,p <br /> COMMENTS: �/(/.(.t'19 <br /> r� " <br /> �GM ' r "� "". (A-A? <br /> e !< vier 6� 'A&a : (e-e+ �� C SO k <br /> SA JOP(Q NME AL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: 0L- EMPLOYEEM -1 DATE: 1.1 (� Q <br /> ASSIGNED TO: �5i l EMPLOYEEM CA DATE: ; 07 <br /> 1a I <br /> Date Service Completed (if already completed): SERVICE CODE: 0 Ce/ P E: /1, _0 Z <br /> Fee Amount: Iry Amount Paid 5 ,6�) Payment Date Ll 36 O <br /> Payment Type L. Invoice# Check# Received By: N <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />