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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 11 d s? 0J <br /> (OWNER I ONE AATO CHECK If BILLING ADDRESS <br /> FACILITY NAME' <br /> ISITEADDRESS <cSo \��l s zbs <br /> �� 4 v i (�,y^ <br /> Street Number Dl�tion �� treBlMame // CI Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) Slit ("�jl � q�e <br /> _ Street N mber <br /> ` w` LStreet Name <br /> CITY.) STAT ZILA PPY 1 S <br /> PHONE#1— f E' . APN# LAND USE APPLICATION# lJ <br /> `oo ) 11. <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> ITREQUESTOR ,� CHECK if BILLING ADDRESS <br /> r <br /> BUSINESS NAME '` t1 IFAx <br /> ` EXT. <br /> ;HOME or MAIL 'ADD ES - i`y ) <br /> {CITY, STATE ZIP <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 SIGNATURE: DATE: I�_/{`�/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTIIORIZED Ak ENT❑ <br /> IfAPPLICANT 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 is available and at tame time it is <br /> provided to me or my representative. Y <br /> TYPE OF SERVICE REQUESTED: A , <br /> COMMENTS: % , <br /> hR oU,N9�0?0 <br /> AD SFT, <br /> MF'1'T <br /> ACCEPTED BY: S EMPLOYEE#: 70 DATE: I <br /> ASSIGNED TO: EMPLOYEE#: 6173'L DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: � <br /> Fee Amount: V 951,VD Amount Paid CI S "o 0 Payment Date `l w <br /> Payment Type 6 Invoice# Check# Receiv d By: _ <br /> v <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />