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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 1D# SERVICE REQUEST# <br /> `W <br /> OWNER 1 OPERATOR <br /> ,L CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS C om, � s;+ r �_ ����- cp <br /> 2 Street Number Direction Street Name s) - city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) ' .l��� ✓ . <br /> CA Street Number W Street Nama <br /> CITY STATE Zip <br /> !�,l <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> '- oN v <br /> PHONE#2 ExT• SOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> -4 �p CA PHONE <br /> if BILLING ADDRESS CI <br /> BUSINESS NAME -4 <br /> Err. <br /> HOME or MAILING ADDRESS FAX# <br /> Ow- ( 1 <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 <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 /> APPLICANT'S SIGNATURE: az v2-L— DATE: (3 2, �2 1 <br /> PROPERTY t BUSINESS OWNED OPERATOR/MANAGER 11OTHER AUTHORIZED AGENT 11IfAPPLICAN//T is not the BILLINGPARTY 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. 4P <br /> TYPE OF SERVICE REQUESTED: Vh �Wvo`� �C <br /> COMMENTS: �S O O <br /> vNyN31p?1 <br /> �[�yo agRN�H� <br /> MFNT <br /> ACCEPTED BY: .` V�/iQla EMPLOYEE#: DATE: <br /> ASSIGNED TO: \J . EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> A'nFee Amount: 2 , Amount Pai /' �! Payment Date <br /> Payment Type Invoice# Check# Ree ved By: <br /> EHD 48-02-425 SR FORM(Golden Rod) <br /> REVISED 1711712003 <br />