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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/OPERA? u�t1[ <br /> U t� � D `l CHECK If BILLING ADDRESS <br /> FACILIry NAME 41 (�o�Y C � �SITE ADDRESS 13L) S r�1 � �^ A3 �} � q52- <br /> 52-L Z <br /> Street Number Direction Street NaMe t City Zip Code <br /> HOME or MAILING ADDRESS (If Di rent from$ite Address) <br /> Street Number Street Name <br /> CITY STATE Z `b 0 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT• BOS DISTRICTLOCATION CODE <br /> { } <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> ` CHECK if BILLING ADDRESS--A— <br /> BUSINESS <br /> DDRESSBUSINESS NAME PHONE# EXT" <br /> HOME or MAILIN ADDR S 1— FAX# <br /> ( } <br /> CITY TATE ZIP t, <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,S - nd+E-D i--laws J 7 <br /> APPLICANT'S SIGNATUR DATE: r 0ZZ L 2 <br /> �I <br /> PROPERTY/BLISINESS OWNEROt OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 the same time it is <br /> provided to me or my representative. �p�y <br /> TYPE OF SERVICE REQUESTED: -� ' VV 1 C4 <br /> COMMENTS: <br /> LAS C1 e�r�P�S r V t YjfLL i DtJt !v•—� OCT <br /> 2 2 <br /> ff ! <br /> H ,�RrTAL TY <br /> ACCEPTED BY: N4 <br /> O V, EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �� P I E: jo3 <br /> Fee Amount: t c;,Z Amount Paid 4 �Sa-� �. Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />