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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �wr�(to <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME111"I 1 ! <br /> -4 <br /> SITE ADDRESS <br /> Er(/�y��7VL S <br /> S'R 1 N .bei Direction roe aN me WC � Co� <br /> HOME or MAILING ADDRESS (If Different from Site Address) Street Number �IVI V S ra <br /> et�Qrne <br /> CITY STATE zip <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> ( " ;,? (/ 1 <br /> PHONE K EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR vlh�)r— <br /> CHECx If BILLING ADDRESS <br /> BUSINESS NAME . PHONE# EXT. <br /> L L4(1 ( ) q-?:�!2 - <br /> 3 Ctrl <br /> HOME Or MAILING ADDRESS ! + 0^>it ( "A /tom FAx#l'f'l'y ( } <br /> CITY / STAT 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 fon-n. <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, S <br /> >TfE and FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: DATE: ! Z <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IJAPPLICRNT is not the BILLING PARTY,proof of atithorization 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: p <br /> COMMENTS: Ivr <br /> CE/1.�� <br /> MM �� 5 �N-1qN 1 ZD <br /> H �11�p NGp <br /> '064A, 7"FNUNrY <br /> ACCEPTED BY: EMPLOYEE M DATE: 7/7, <br /> ASSIGNED TO: v ® n EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: 1 O� <br /> Fee Amours fS2'Gu Amount Pa i /6a' OD Payment Date ! <br /> Payment Type Invoice# Check# Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />