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SAN JOAQ: _ COUNTY ENVIRONMENTAL HEALTH . .'ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property / FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS r c. 3rJ� i <br /> Street Number Direction Street Name Cf Zin Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) G <br /> L Stree[Number �/ � Street Name <br /> CITY STATE ZIP q ,5'1->'o <br /> I <br /> PHONE#1 ExT APN# LAND USE APPLICATION# <br /> + (2 > - P/O0A/n <br /> PHONE#2 /J EZT. BQS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> ( ) <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 or <br /> 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 JOAOUIN <br /> COUNTY Ordinance Codes, Standar TATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ` l-�f �� DATE: / <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,Proof Of authorization t0 sign is required Tirle <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment' formation <br /> t0 the SAN JOAQUIN COUNTY ENVIR014MENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time it i5 provi e or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: ( ^h t001t t f� 5610 — (,9/t,t. eZA- <br /> COMMENTS: 7- <br /> ACCEPTED <br /> �q� Fp M1114 <br /> BY: I ' l /1n^ ' EMPLOYEE#: DATE: r-t <br /> ASSIGNED TO: Y V ) a EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: f P/E: ! <br /> yY, i <br /> Fee Amount: Z -� Amount Paid C/y/�,bD Payment Date ��// 9 <br /> Payment Type Invoice# Check# Received By: <br /> //21 <br /> 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />