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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �:7p 2 S4 WRHq z22 <br /> OWNER I OPERATOR CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS 2 j7] !/'2 c"?— <br /> Street Number Direction Street Name Cit Zip Code <br /> HOMEorMAILING ADDRESS (If Different from Site Address) r1 10 '/7�� <br /> G �C1 Q S ( Street u / <br /> mber �' / Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT- APN# LAND USE APPLICATION# <br /> PHONE#2 EXT- BOS DISTRICT LOCATIDN CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS El <br /> BUSINESS NAME C� PHONE# EXT' <br /> & • C Ca� <br /> HOME or MAILING ADDRESS j� FAX# <br /> e- C 6 S P ( ) <br /> CITY ce" STATE / ZIP 5~ <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 /> 1 also certify that I have prepared this application and that the work to be performed wil I be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDEL laws. <br /> "/2 <br /> APPLICANT'S SIGNATURE: ars /�C Gy�i �� DATE: — G <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGL•'NT❑ <br /> 1fAPPLiC4NTis not the BILLING PARTY,proof of authorization to sign is required Tule <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#Qd at the same time it is <br /> provided to me or my representative. i p A Yom�++ <br /> TYPE OF SERVICE REQUESTED: LI�1/l cct 1/lS C1V <br /> COMMENTS: Y <br /> 11 <br /> �M"VvK- op o„� � %JoAQ ° <br /> 111�6D� W'c�NT� ry <br /> MINT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODS: ; PIE: <br /> Fee Amount: tS-2 Amount PaidPl 512r Payment Date <br /> Payment Type Invoice# Check# R ceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 Uq �� <br />