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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 A v i All V Z / 7 . - CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS Q ELI , S0 -T �'1(41 <br /> Street Number Direction Street Name Cit,_` Zi Code <br /> HOME Or MAILING ADDRESS (I}Different from Site Address) * // <br /> (y Streetv1Num_ber �L(Street Name <br /> (/Y0A <br /> 7 <br /> CITY /• u,' STAT ZIP 41— <br /> PE#) EXT APN#410,./30DLAND USE APPLICATION# <br /> - <br /> PHONE#2 EXT. BOS DISTRICT �— LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> i BUSINESS NAME •t PHONE# EXT. <br /> HOME or MAILING ADDRESS /�/�j t./r' Pi FAX# <br /> CITY A CLI <br /> STATE C�4 ZIP t <br /> BILLING ACKNOWLEDGEMENT: 1. the undersigned property or business owner. operator or authorized agent of same. <br /> acknowledge that all site and/or project specific Il:NVIRONMENTAI. HEALTH I)EPARTmr:NT 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 I-E <br /> APPLICANT'S SIGNATURE: _. DATE: <br /> PROPERTY/BI?SINESS OWNER- OPERATOR/MANAGER ❑ OTHER AUTFIORIZED AGEN'r❑ <br /> /fAPPLICANT is not/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/ 'te assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at AI�C'/(j�it is <br /> provided to me or my representative. / ��� A, <br /> TYPE OF SERVICE REQUESTED: S , I �•:i ; l f" nC� N <br /> COMMENTS: eYn-1,lleGl oil x91171a0,W P,,yiweyl� feeetVv;4 )DA�oV017c SqN✓pq ?�ZQ <br /> NFq TN Dp <br /> COUV <br /> RTNjENT <br /> ACCEPTED BY: �� EMPLOYEE M DATE: L dv � <br /> ASSIGNED TO: < < EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: �O Amount Paid-560 .Q� Payment Date /D Z <br /> Payment Type Invoice# Check# �U� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />