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r <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property <br /> FACILITY ID# SERVICE REQUEST# <br /> OWNERI PERATpOR��,c1 ,S On c� CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS �J ��)V� (�tl- S1 uG C"'�J 7's� <br /> 3o[� Street Name Ci Zi Cede <br /> s'LtNumber Direction <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> STATE Zi <br /> CITY <br /> EXT. APN# LAND USE APPLICATION# <br /> PHONE#1 _ <br /> ( ) LODa^.Ot:GIDE <br /> `EXT. OOS DISTRICT <br /> PHONE#2 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> ®REQUESTORT ... CHECK 1f BILLING ADDRESS <br /> P � /Rill.��. PHONE# �—�+� EXT. <br /> J77��.T��FAx# <br /> ADOR S5G/3- real7''77 STATE <br /> BILLING ACKNOWLEDGEMENT: 1, 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,STA d FEDERAL <br /> APPLICANT'S SIGNATURE: �� DATE: <br /> PROPERTY/BUSINESS OWNER❑ O TOR/MANAGER El/ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTP 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 environmentaUsite assessment <br /> to tl SAN JOAQUrN.COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it IS <br /> provided to me or my representative. �1 _N <br /> TYPE OF SERVICE REQUESTED: 'J / / / AYM� <br /> R <br /> COMMENTS: 205 <br /> APR 1 <br /> SAENVt pNME M ttT <br /> 1H DEPA <br /> _-- <br /> ACCEPTED BY: EMPLOYEE#: q�� DATE: <br /> . <br /> ASSIGNED 19 /In C EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E <br /> Fee Amount: ., Amount Paid $�]�, C p Payment Date l-� ('� D S <br /> Payment Type L/ Invoice# Check# -l�� ReceivedBy:w� - <br /> SR FORM(Golden Rod) <br /> EHD 4M2-025 <br /> REVISED 11/17/2003 <br />