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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OP)RAT Is^ <br /> /ff\ CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS C�t/?— <br /> o� Street Number DI tlo `LStreet Narme` CI Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#I EXT. APN# LAND USE APPLICATION# <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ^ \ CHECK if BILLING ADDRESS E] <br /> BUSINESS NAME �i �u 1�.•_��1�/w,. PHONE# EXT. <br /> r� ,�? 5-1) (a -3 O1. <br /> HOME or M:I N;AD/RESS FAx# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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. �f <br /> APPLICANT'S SIGNATURE: �e�✓�'/f� DATE; O / Z Dd. D <br /> PROPERTY/BUSINESS OWNER LJ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Titre <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. p <br /> TYPE OF SERVICE REQUESTED: IF0d 006 1 N�_ 41�1 �T <br /> COMMENTS: A//^ O <br /> s�✓o 12020 <br /> h FNS/RO U/N C� <br /> )'Ho p'HFNT 1,v <br /> '9RT,HFNT <br /> ACCEPTED BY: & EMPLOYEE#: DATE: <br /> ASSIGNED TO: J, YO.-LCk EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICECODE: c�2� P I E: \�(� <br /> Fee Amount: kAA <br /> Amount PF�15G uU I <br /> Payment Date YW <br /> Payment Type Invoice# Check# 1 2—q Z Received By: <br /> EHD �4 ��n SR FORM(Golden Rod) <br /> REVISEDSED 1 <br /> 11/1/1 7/2003 L <br />