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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 7 '4 )-qu T <br /> OWNER 1 OPERATOR <br /> CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS ''Z(�� ^� f W I V Jr nor Cy Loa\ 5 Zz <br /> Street Number Direction Street Name cit, ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) '2-L ro (;e 0 C'-Ae <br /> Street Number Street Name <br /> C ITY STATE ZIP <br /> Ocg S 3 a <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> PHCNE#2 Ex-r. BOS DISTRICT LOCATION CODE <br /> { <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> �j CHECK if BILLING ADDRESS <br /> BUSINESS NAME {{ I PHONE# <br /> A Exr. <br /> t W �C } 2 <br /> HOME Or MAILING ADDRESS FAX# <br /> Z vv L ( ) <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 farm. <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: •t - DATE: ? 2� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZE])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: <br /> 1 �0 20 <br /> N R Co. 20 <br /> z F N <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: fib' V v�vt/fQ EMPLOYEE#: DATE: <br /> Date Service Completed (If already Completed): SERVICE CODE: I f PIE:E. ���-Z <br /> Fee Amount: Jli- 1�2 1 Amount Paid J���^ Payment Date !2L31-2 <br /> Q <br /> Payment Type Invoice# f Received By: <br /> GU trEHD 48-02-025 SR FORM (Golden Rod) <br /> REVISE=D 11/17/2003 ek*o2 393 <br />