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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Z&I _ ? 5Q <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> t,q � � <br /> FACILITY NAME <br /> SITE <br /> ADDRESS /M � � 12,-J , G�7r/7-- <br /> I/7 Street Number I Direction ' Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street NumberT Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT APN# L� LAND USE APPLICATION# <br /> pq <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUIjSTOR / CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT. <br /> II����` ���� <br /> TfJ ✓9 /�5 tiS l <br /> HOME or MAILING ADDRESS FAX# <br /> CITY ��C- /�� STATF - 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 FED AL laws. / <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHERAUTHORIZEDAGENT$ <br /> IfAPPL/CANT 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 at the same time it is <br /> provided to me or my representative. <br /> 74 r <br /> TYPE OF SERVICE REQUESTED: �PJ L re V )'r 1-1 �NT <br /> COMMENTS: CD <br /> .11JL 15 20 <br /> IV H ENV/RONIN COUN <br /> EACTy DE MFNT <br /> ACCEPTED BY: �� � 1/� EMPLOYEE M DATE: '24 O <br /> ASSIGNED TO: J�I EMPLOYEE M DATE: dJ k) <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: o7�(,Jpa <br /> Fee Amount: J ' Amount Paid Payment Date <br /> Payment Type Invoice# Check# cam— I '�� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />