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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST P IZ D I (o o <br /> Type of Business or Property FACILITY ID# SERVICE REQU T# <br /> ST D- <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME—,�r�l �� Ce <br /> SITE ADDRESS I (D0r�fy <br /> Street Number Direction / Street Name .J C'It", / vZi Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PONE#1 EXT. APN# LAND USE APPLICATION# <br /> S) 777 3 <br /> PHONE#2 Ex . BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> R:EQUESTOR - <br /> _ C I f �/1 CHECK If BILLING ADORE55� <br /> �! V`'Y <br /> BUSINESS NAME Mv1'l I 0C•J( aGe PHONE# EXT. <br /> ' <br /> HOME or MAILING ADDRESS ,Y FAX# <br /> CIU <br /> CITY ATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business Owner, operator or authorized agent oll 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 Coder,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: (:' �h. DATE: <br /> PROPERTY/BUSINESS OWNER q( OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> I'APPLICANT 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 i5 available and at the same time it is <br /> provided to me or my representative. Aknqp <br /> TYPE OF SERVICE REQUESTED: ,O ` C ` <br /> COMMENTS: NOV�JOgQI/I 3 20?O <br /> UQ \ N�C�RONM COVN <br /> ACCEPTED BY: 1 EMPLOYEE M DATE: I <br /> ASSIGNED TO: PA�(Avel <br /> EMPLOYEE#: i7r n DATE: ' <br /> Date Service Completed (if already completed): SERVICE CODE: 4'W PI I�� <br /> Fee Amount: Z Amount Paid/Sal C/6 Payment Date <br /> Payment Type Invoice# Check# Receivdd By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />