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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property _ FACILITY ID# SERVICE REQUEST# <br /> SQ 00Sq ZlP Z <br /> OWNER/OPERA OR <br /> _ r CHECK If BILLING A00RES5� <br /> FACILITY NAME <br /> SITE ADDRESS I I V 1'r�t�t✓(/ Vl/I, M n I C D <br /> Street Number Direction Street Name Cit ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#I Em' APN# LAND USE APPLICATION# <br /> ( ) z63- <br /> PHONE#1It Exr. BQS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR `a '( <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEJ ` PHONE# EXT, <br /> v7 iq <br /> HOME O MAILING ADDRESS CJ f(•',/t/(J FAX# <br /> ( ) <br /> CITY STATE 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 anj that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAT and F laws. <br /> APPLICANT'S SIGNATURE: ��" �A <br /> r�..// DATE: Z L-I <br /> PROPERTY/BUSINESS OWNERaO OPERATOR/ AGER ElOTHERAUTAORIZEID AGENT <br /> IfAPP6rCANT is not theBILLING Pi RTY 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 %alt' sante <br /> the time it is <br /> provided to me or my representative. '—fI YAli <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> SAN jo.4QU <br /> ly 'INVIN cou <br /> P-qL <br /> THtriDOPAR ALN1y <br /> i If <br /> ACCEPTED BY: EMPLOYEE#; DATE: 2 <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O� PIE: 2 <br /> Fee Amount: l2 Amount PaId2 �S z,(� Payment Date 2 <br /> V2- <br /> Payment <br /> Payment Type Invoice# Check# Receiv By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />