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r r <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business orroperty FACILITY ID# SERVICE REQUEST# <br /> MI\ N\� _,, Q (nel?-gq7 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> O <br /> FACILITY NAME <br /> �- <br /> SITE ADDRESS 1..1e,., h�ZU'� <br /> Street Number Dlrectlon treat Name Cil ZIP Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) �(l�7 t/J�1 <br /> Slraet Number Street Name <br /> CITY STATE ZIP <br /> PHONE#f En. APN# LAND USE APPLICATION# <br /> W) L <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> d CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# O Em <br /> HOME or MAILING ADRESS FAX# <br /> 1� U ( ) <br /> CITY STATE ZIP /x <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 1 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 /> PPLICANT'S SIGNATURE: �n 5C I Z /y<lY✓GYC CS7y�Gf DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT i3 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 th�ante time it is <br /> provided to me or my representative. Ay <br /> TYPE OF SERVICE REQUESTED: c, <br /> COMMENTS; 4% <br /> Vl,09l l C lknil H 42QV/N <br /> ��,q�� J� GjYt(� ��QfpgRH�NrY <br /> ACCEPTED BY: I Q V`l/l1^ C EMPLOYEE#: �I DATE: I I� <br /> ASSIGNED TO: v�1 V�1 J EMPLOYEEM - DATE: l w <br /> Date Service Completed (if already completed): SERVICE CODE: I PIE: U <br /> Fee Amount: 'U Amount Paid /5� D Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />