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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# 5 RVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> man C1 e&40 <br /> FACILITY IVAM5--,I— <br /> SITE ADDRESS Cy <br /> Street Number Directlon I` Street Name Cit / ode <br /> HOME Or r1lIAILINGIADDRESS (If Different from Site Address) <br /> 4 C Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t Exr• APN# LAND USE APPLICATION# <br /> (ego ) 4�? Li <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUE$TOR ,n +n p� <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME �_ /1 _ � PHDEXT. <br /> L'A <br /> HOME or MAILING fADDRESS FAX# <br /> 6-4 ( ) <br /> CITY T TE ZIP <br /> BILLING ACKN WLEDGEMENT: 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 /> -PROPAPPLICANT'S SIGNATURE: _y DATE: a-3- <br /> PROPERTY <br /> ERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLlcANT 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: Air— <br /> AY <br /> COMMENTS: CE'``t�y <br /> e ieb <br /> cffL (A JANe5Zt <br /> '11kVtNM C°UN1Y <br /> mop �Nr� <br /> ACCEPTED BY: a �, EMPLOYEE#: q,130 <br /> DATE: ? 2I <br /> ASSIGNED TO: r EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: `> y_ Amount Paid 15a; Payment Date IN + <br /> Payment Type Invoice# `Check# Received By: 1 <br /> EMD 48-02-025 A C SR FORM(Golden Rod) <br /> REVISED 11/17/2003 l•C <br />