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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FT19 �00��q�V <br /> -O L", <br /> OP TO� CHECK ifBILLING ADDRESS <br /> 4a �CI <br /> FaciuNA <br /> � ME <br /> SITE ADDRESS u �71 �CG <br /> � S�f�� '"a O <br /> $n �! <br /> � /tiet Number Direction I Street Name Cit Zi Code <br /> HCIOr MA ING DDRESS (If Different from Site Addie s <br /> Street Number Street Name <br /> CITYf STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 c� Exv• BOS DISTRICT LOCATION CODE <br /> l ) <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> 17"TOCHECK if BILLING ADDRESS <br /> BUSINE NA�1 ^ P ONE# Exr. <br /> L /1 G <br /> HOME or ING ADDRE S FAX# <br /> L <br /> ITY T' E zip / % 1 <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 an FEDERAL laws. <br /> APPLICANT'S SIGNATURE: Z,�/a U12DATE: <br /> --PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER 13 OTHER AUTHORIZED AGENT❑ <br /> 1J'APPLICANT 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 the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: �J LOrS�I <br /> COMMENTS: 4-11 twir 14 1 <br /> REC,EIVEQ <br /> '-)EC 0 8 BOZO <br /> sE E JOAQUIN COUNTY <br /> ENIiIRONM T <br /> ACCEPTED BY: EMPLOYEE#: 1l a DATE: <br /> ASSIGNED TO: EMPLOYEE#: 9 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Cly <br /> Fee Amount: A 1 '6,Q Amount Paid Payment Date <br /> Payment Typeu Invoice# Check# Received By: <br /> EHD 48-02-025 vV' ! i -1- 3 -5-0 rl SR FORM (Golden Rod) <br /> REVISED 11/17/2003 f P)'Z1 &51 <br />