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SAN JOAQL COUNTY ENVIRONMENTAL HEALT. EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> O ER/OPERATOR <br /> (l Q o o� <br /> FACILITY NAME ip 1� CHECK If BIaLLING ADDRESS <br /> .- l rip 9 <br /> G Yh <br /> SITE ADDRESS �LClt kL ?Z5i �L <br /> Street'Number Deion Stee�Name <br /> Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> ,rye -�' -m 3 3 L <br /> 3� `� A� L Street Number � Street Name <br /> CITY STATE zip <br /> L Qp <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAx# <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 ENvrRONMENrAL 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 FEDERAL laws. i <br /> APPLICANT'S SIGNATL E:'� t, _ /� t(�^� DATE: 1 / <br /> PROPERTY/BUSINESS OWNER❑ O RATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICAIVT 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 theme time it is <br /> provided to me or my representative. (` qy/ <br /> TYPE OF SERVICE REQUESTED: 12 <br /> COMMENTS: /APR <br /> OMMENTS: c, `� / SAN JO l O�o 4 <br /> / t � �'S }o NE�N%q UtN C / <br /> ACTH OO 40-Ai- <br /> ACCEPTED BY: V f r i r-a,u-i�t EMPLOYEE#: DATE: <br /> .1 -O <br /> ASSIGNED TO: 1 VA- EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: p 6 P 1 E: �3 <br /> Fee Amount: `Z 7 J Amount Paid pbaj U�i Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />