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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 3a'Iwc� 5a17032cl DD <br /> OWNER I OPERATOR <br /> Y � CHECK if BILLING ADDRESS <br /> FACI NATIE_ <br /> SITE ADDRESS SdoG r, 932j� <br /> / Stmet Number Dlreetlon Street Name Ci V Zi Code <br /> HOME or MAWNG&DDRSs <br /> If D/ rent from Site Address) <br /> OBJ pG Street Number Street Name <br /> LF r vTA zip /Q <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / CHECK if BILLING ADDRESS <br /> SIN SS NAn1 PHD if d# —Y � En. <br /> 57,77 <br /> HOME or MAILING ADDRIESS FAX# <br /> CIN A ro 'Sd '-7 CSW <br /> E zip ) 3� <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'S SIGNATUR DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT LT 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 environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at tame time it is <br /> provided to me or my representative. ) AY <br /> TYPE OF SERVICE REQUESTED: <br /> t1(( (� VMr �VV �/`�'�./ CF <br /> COMMENTS: �� lV l 1 l�� V� �,At _ n �✓ �/ ���� <br /> �CTy�FPMFNONN7y <br /> aRny N> <br /> ACCEPTED BY: A <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: V A <br /> EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICECODE: D PIE: VZ <br /> Fee Amount: (- Amount Paid /S dU Payment Date <br /> Payment Type invoice# Check# Z R ceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />