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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//OPERATOR <br /> CHECK if BILLING ADDRESS O <br /> FACILITY NAME (ALss I/ ' <br /> SITE ADDRESS l� -71LT-�zz1g)-Co)de-' <br /> Street Number D rect o Y14 t]et Name �1 U� ��CI U� <br /> HOME or MAILING ADD ESS (If Differs t from Site Addre <br /> L" Q '(I t Street Number Street Name <br /> CITY L�k�)r J STATEC A ZIP <br /> PHONE#1 / EXT. APN# LAND USE APPLICATION# <br /> (Zv"Il y"�1 - U32b <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR i <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS (� I��3 ,Ax# , <br /> CITY I STATE I ZIP 5-3 2C <br /> BILLING ACKN WLEDGEMENT: 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,Stand�Sn ERAL laws. <br /> APPLICANT'S SIGNATURE- DATE: I <br /> PROPERTY/BUSINESS OWNERPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11If APPLICANT is no he 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 /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> P Y E <br /> J N <br /> 6 S 1 <br /> /(JI p 6 202 <br /> ACCEPTED BY: EMPLOYEE#: DATE:(11 aa QYN ry <br /> ASSIGNED TO: f y EMPLOYEE#: �E' / DATE: I � TM� <br /> Date ServiceCompleted (if already co pieced): SERVICE CODE: P/E: /�7G12 <br /> Fee Amoun : Amount Paid Payment Date <br /> Payment Type r Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />