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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACI6.171-Y Ib# SERVICE REQUEST 912 <br /> 7 <br /> lie- <br /> OWNER 1 OPE_M+TOP <br /> f n _ CHECK if AJLLING AnoREss❑ <br /> FACILITY NAME <br /> SITE ADDRESS <br /> =ao <br /> �- SS�+' Street Humber O:rcIXion •r'��l rf gtreet me c <br /> HOME or M LING ADDRESS (if Different from site Address) :1 <br /> 3C-C' �� n A A�� <br /> 1/�Cr�1� vY StreN Number SIreM Hama <br /> Cil'Y STAT ZIP <br /> �. CGr Y"1 UG <br /> PRONE 91 E 7• APN# 0 U5E APPLICATION# <br /> c? f l `ICS-9 q - if% - t ,�/fi <br /> PH0NE#2 ar• BDS DISTRICT t_oCATION COOS <br /> (Zrrll-1 gcJ. -I w5 <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOft <br /> CHECK If EILLIN9 ADDRESS <br /> BUSINESs NAME PHONE# • <br /> l <br /> HOME or MAILING ADDRESS FAx# <br /> { <br /> CITY S7ATE 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 JOADUIN <br /> COUNTY Ordinance Codes,Sraadan*,STATE and FEDERAL laws, <br /> APPLICANT'S SIGNATURE:�� 4 DATE: —Lr—2 t <br /> PROPERTY BUSINESS OWNER El OPERATOR/MANAGER❑ OTHER AUTHORIZED AGEVT❑ <br /> If,9PPLlCAN7'i5 r+Or lire BILLING PAR7Y proof of authorization to sign is required rill <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,[,the Owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geolechnical data and/or environmental/site assessmcltt <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMFNT as soon as it is available and at the same time it is <br /> provided to me or my repres entat i v C. <br /> TYPE of SERVICE REQUESTED: F04 rl�tA' <br /> CQMMfN75: <br /> 71 <br /> 4PA'0e�ED <br /> d0'.q IN <br /> ACCEPTED BY: EMPLOYEE#: DATE: 7Ir <br /> Ass]GNEO TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SEavICECoaE: p i E: <br /> i 410 <br /> Fee Amount: Amount Paid f S� Payment Date <br /> Payment Type Invoice# Received By: <br /> EHE}48.02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />