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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> a <br /> OWNER/OPERATOR <br /> Q�rlo I + I G CHECK If BILLING ADDRESS <br /> FACILITY NAME J l V <br /> SITE ADDRESS / Q j _7 LI �Y/ LP 64 /�OILL�j1 (G/YY1( <br /> Street Number Direction Street N e Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 'r <br /> l Street Number V Street Name <br /> CITY STATE Zip <br /> -FrYIAC (� Cof w <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME (� Y PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITYr�/r uC �` $TATE 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: - DATE: L�J <br /> PROPERTY/BUSINESS OWNE OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El <br /> If APPLICA 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<1 < CIL, 117" (i)ld [VI I t t e4c, <br /> COMMENTS: <br /> CF jVEC <br /> s gNFIEe 2 20,21 <br /> H EN 1RONjOAQUM COUNTY <br /> �L'rNgn.FNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 't AF- �1�T <br /> ASSIGNED TO: EMPLOYEE#: DATE: "ids d r <br /> Date Service Completed (if already completed): SERVICE CODE:; ; P/E: 6aE cd <br /> Fee Amount: 44 D,� Amount Pai QXU0 Payment Date Z <br /> Payment Type Invoice# Check# Receiv d By:/ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />