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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gene( S ( R 1374 �✓�0����2� <br /> OWNER I OPERATOR <br /> S / Va CHECK I(BILLING ADDRESS <br /> FACT RAMS a/ZIDC ' 67. or <br /> SITEADDRESS 29�s RCWBAr 0&5:: F37777 <br /> Sbeel Number Direction Street Nome CI ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZP <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> (Uq) 41L( 82zll�a_ <br /> PHONE#2 Exr. SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> R;EQUESTOR CHECK If BILDNG ADDRESS <br /> BUSINESS NAMERIedMd � C7( _ JQ� ! - PHONE# EZT• <br /> 61 eHOME or MAILING ADDRESS � ��" V ,J FAX# <br /> Jew I ) <br /> CITY "t'rq STATE LP <br /> cj�BILLING ACKNOWL GEMENT: 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 /> 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 and FEDERAL laws. l <br /> APPLICANT'S SIGNATURE: ' 2& z DATE: 0 `��.ZI <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> IjAPPLtCANT is not fire B&LING PAKrr proof of autboriration 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 envirgnmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available�;��yl�lite same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: N-r- � <br /> COMMENTS: UG <br /> SA NVC)q UIN <br /> Q <br /> .. kEq�tN aeP�e N 7. <br /> t <br /> ACCEPTED BY: tci�'r-(1_.(�_SGp EMPLOYEE#: DATE: <br /> ASSIGNEDTO: �'yL S EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 0(p PIE: b p rL <br /> Fee Amount: S� Amount Pai 6D Payment Date S 2,ef <br /> Payment Type ' Invoice# Check# &' S..x__JAb6 Ftceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />