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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> . I CHECK if BILLING ADDRESS <br /> FACILITY NAME N � <br /> I N E--1-17 /� <br /> SITE ADDRESS S //� }N Ut <br /> Street Number Direction 444 Street Name f— Cit 'T r Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) ( / // <br /> Street Number `�1 ` Stree6!ame <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> I 6.2 7s� <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> 17EQUESTOR KE WA <br /> A J 6 CHECK If BILLING ADDRESS <br /> BUSINESS NAME /V PHONE E.. <br /> Z �D $SS <br /> HOME or MAILING ADDRESS FAx# <br /> csv ( ) <br /> CITY S O ` 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 Codec,Standards, STATEandFEDERAL laws. �yy <br /> APPLICANT'S SIGNATURE:• Ke- Vy / DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PART 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. n <br /> TYPE OF SERVICE REQUESTED: O/ ' <br /> COMMENTS: ' <br /> pq <br /> � <br /> y F� <br /> ACCEPTED BY; EMPLOYEE#: ?v Eltn,. �.�, l 2(} <br /> ASSIGNED TO: V' at/}t EMPLOYEE#: •�7 <br /> Date Service Completed (if already completed): SERVICE CODE; P <br /> Fee Amount: Paid Payment Date <br /> Amount <br /> Payment Type Invoice Received By: <br /> EMD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 � ��� r1�� S' <br />