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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> r o 6� s�- ODSS36b <br /> OWNER/OPERATOR c �/�- � <br /> p ��0+_1D CHECK If BILLING ADDRESS <br /> FACILITY NAME 9KAO 1 MS P1?7-A 7 !, <br /> SITE ADDRESS +\ f(Y�I C�� 0"'v <br /> Street Number Dlractlon f�•' Street Name ��� Cit Zi Coda <br /> HOM r MAILING ADDRESS (If Different Tom Site <br /> Address) <br /> 2- �6 O O ' `P' ` 1 Street Number Street Name <br /> CITYuAI (OIV IV STATE 1. e/1 ZIP �rQ' <br /> PHONE#1 MVV 1 V ` `I 1 Ems' APN# LAND USE A`P'PLLICATION# <br /> ( SW) 6� q I I 1 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> rJ CHECK((BILLING ADDRESS <br /> BUSINESS NAME V PHONE# Ex . <br /> HOME or MAILING ADDRESS FAx# <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 E WS. <br /> APPLICANT'S SIGNATURE: DATE: S <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 1:1 <br /> If APPLICANT isnot iheBILLINGPARTYproofofauthorizationtosign isrequired 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: <br /> Pit- <br /> COMMENTS: D <br /> MAR 5 <br /> 20?1 <br /> H f�RO INCOU <br /> E,gCTyo��N��NT <br /> ACCEPTED BY: EMPLOYEE#: / DATE: <br /> ASSIGNED TO: EMPLOYEE#: t DATE: <br /> Date Service Compl ed (if already completed): SERVICE CODE: P/E: Ip Z <br /> Fee Amount: 2� Amount Paid Payment Date 2A <br /> Payment Type Invoice# et ei keceived By <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11/17/2003 <br />