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a <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTh DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I _ OR� //// / J <br /> CHECK If'BILLING ADORES <br /> t. <br /> FACILITY NAME G / D 5 A z-{^� f <br /> SITE ADDRESS V� t_ C�Ji 1 uyt 1�1� Sr`^ ST`—` Lt L o <br /> Slree[Number Direction Street Name Cil Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3�6 O SLt IANL1 R� <br /> Street Number Street Name <br /> CITY STATE ZIP S <br /> PHONE#1 Err, APN# ,1 O` `L LAND USE APPLICATION# <br /> �� l � <br /> !20-f ) 82`l 8 S � 4 ` <br /> PHONE#2 ExT. BOS DISTRICTU \ LOCATI0�CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS , <br /> BUSINESS NAME PHONE# ERT' <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 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 FEDERAL laws. <br /> APPLICANT'SSIGNATL �� ' �77���T DAIS <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IJAPPLICANT is not the BILLING PAR TP 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: r+ppt 'V.Oilhl�'C YIi'j '� <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: - DATE:' <br /> ASSIGNEDTO: lU t SSC W\ EMPLOYEE#: DATE: ' <br /> Date Service Completed (if already completed): SERVICE CODE: Ob l P I E. <br /> Fee Amount: 1770° Amount Paid '�' Payment Date g' /A( <br /> ype <br /> Payment TInvoice# Check# ReceivedlBy: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />