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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY Ip# SERVICE REQUEST# <br /> OWNER I OPERATOR �� <br /> I �+r CHECK if 81LLING ADDRESS 1 fr I <br /> { r <br /> FACILITY NAME S <br /> � ill <br /> SITE ADDRESS <br /> ,( 01 •`,nom <br /> t4o <br /> L G� Street Number Dlrecn `5'treet Name Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE 91 Exr, APN# LAND USE APPLICATION# <br /> (7 ) L <br /> PHONE#2 FXT• BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAx# <br /> CITY . L STATE zip <br /> L� I G Lj <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,Standards,STATE a EDERAL laws. <br /> APPLICANT'S SIGNATURE: C � DATE: � <br /> ROPERTY I BusiNESs OWNER OPERATOR/MANAGER ❑ OTHER AUTF[owz r)AGENT❑ <br /> IfAPPLICANT is not the BILLING PAR I: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 salve time it is <br /> provided to me or my representative, <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> C�JCLVAe no AIJG 09 . <br /> SAty Jo ?021 <br /> Hr "�r�RolvM o�rnrry <br /> H o'E�p, r-rAtNr <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: r , � EMPLOYEE C / DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: G P i 2— <br /> Fee Amount: �tj - Amount Paid �.� Payment Date 121 <br /> Payment Typecaad Invoice# ec 2CO3� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />