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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST P R 0 51,11,65 q <br /> Type of Business or Property FACILITY ID# SER ICE REQUEST# <br /> s�0d-Q-9- <br /> OWNER/ ERA OR <br /> CHECK It BILLING ADDRESS <br /> FACILITY NAME y <br /> SITEADDRESS 806b <br /> Street Number � DIrection <br /> p� Codo <br /> HOME or MAILING ADDRESS (If Different from Site Address) �C) C-kaS� CF- <br /> wet Name <br /> CITY �O STATE ZIP52Z)V / <br /> PHONE#i ExT• APN# LAND USE APPLICATION# (� <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> 0!9) 4zo - gZ`/D <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUEST <br /> CHECK If BILLING ADDRES <br /> BUSINESS NAME \ <br /> PHONE Ex' <br /> V. 2G - 2 <br /> HOMEor I I ADDR S FAX# <br /> 0. G ( ) <br /> CITY - STATE <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,Standard TATJan FEDERAL law <br /> APPLICANT'S SIGNATURE: DATE: l ZOZ� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br /> If APPLICANT 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: <br /> COMMENTS: Y <br /> JRFcFM�or <br /> N� <br /> y FNj,OgO(rj91 <br /> ACCEPTED BY: EMPLOYEE#: 1�p 2jo <br /> ASSIGNED TO: C, EMPLOYEE#: DATE: /y <br /> Date Service Complete& Ilf already completed): SERVICE CODE: ( 3 P 1 .rrl�6 <br /> Fee Amount: 5 - Amount Paid Ts U Payment Date tel I "l 2Z <br /> Payment Type Invoice# Check# Received By: Lib <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />