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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. <br /> SERVICE REQUEST <br /> Type f Business or Property FACILITY ID# SERVICE REQUEST# <br /> \ati I 00 <br /> O N�O TOR <br /> CHECK If BILLING ADDRESS <br /> /Pa"F NAME <br /> ITE A�D'D�RES -reep <br /> v✓ Stt Number Direction Streeit/N(aJmle�, Ci 1 Zi Code / <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) I D 5 2-0©o :�' P'4 -C&0 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> R UESTOR te=:O_ <br /> y� CHECK if BILLING ADDRESS <br /> Omjbm <br /> B ESS NAAIIE , fPHONE# EXT. <br /> HOME or MAILING ADI ESS QF <br /> FAx# <br /> CITY STATE zip Ca <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. 129 <br /> /� -�/�) <br /> APPLICANT'S SIGNATURE '(/� �✓ DATE: / <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PAR TY,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. L <br /> TYPE OF SERVICE REQUESTED:So J <br /> COMMENTS: R"- reee;tlea by SYx-W !. /V T <br /> O <br /> N�OCr 3Q <br /> Sg ?0? <br /> NFq r' Q MFNouN Y <br /> qR 4� <br /> ACCEPTED BY: EMPLOYEE#: j Q/� J�C DATE: )Id q/dpi <br /> ASSIGNED TO: ! c EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PlE: <br /> Fee Amount: Amount Paid' (��? d6 Payment Date 1� 2 <br /> Payment Type Invoice# Check# Z �(p� Received By: / -) <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />