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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 9� Noy r <br /> SERVICE REQUEST (d ocy)q t 3-74rf7 1„s tt me <br /> Type of Business or Property FACILITY ID# n SERVICE REQUEST# <br /> J <br /> OWNER I OPERATOR <br /> CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> ((T;;,,E ADDRESS <br /> L t Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) ^w 4� <br /> Street Number Street Name I��'1! �� <br /> CITY STATE ZIP NA4zel l) <br /> PF- <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# tf 152112, <br /> PHONE#2 EXT• BOS DISTRICT L61 tF1VT Tr <br /> ( ) s OEpART QL <br /> ANT <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUEST > <br /> L— ,`�' �`�� `)N /�/rel CHECK If BILLING ADDRESS <br /> BUSINESS NAME (Dz PHONE# EXT. <br /> HOME ol'�WILING ADDR SS FAX# <br /> CITY C STATE ?, ZIP ;J 3 <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,Standard. ATE and FED mss. i <br /> APPLICANT'S SIGNATURE:L ')JV) ekcDATE: S l <br /> PROPERTY/BUSINESS OWNERS 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: IP(�� ►Y'S�c;I�G Ur' d �� r��e�:� �=,�. k'- I� tP dP✓f}� 11 (JSP J,'�N CJ Yt(ISCy pf" 1F' f <br /> COMMENTS: <br /> Pr'r C1 " <br /> CA FA 1?�3I C3IoMP5 I< well kxo. •� u�q pu-r,'ei CX S7��O�z� i s t,(k'75 �,caef <br /> bCGkFi�,:� p��ve;�Itl�:n afev:teG,n6lsc:bvl�'l� t�:p �t3vJ I�PI� i��;5loeet� c1ss 7r�� 6as7dt406" : <br /> ShrNe t�,lcltess rem��l�s <br /> ACCEPTED BY;�� 1� EMPLOYEE#: DATE: r/y�J <br /> ASSIGNED TO: DA r EMPLOYEE#: DATE: ���/d� <br /> Date Service Completed (if already completed): SERVICE CODE: �� P,E: <br /> Fee Amount: )Sp2 Amount Pa O� Payment Date /2 <br /> Payment Type '1 t-t Invoice# Check# �3`Ssb Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />