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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE R QUEST# <br /> -FA MC)I`1 *1 0 D& 22 <br /> OWNER/OPERATOR�� <br /> a/�.y ✓ C S CHECK If BILLING ADDRESS <br /> FACILITY NAME \ l (1 <br /> a h ctn4 F . <br /> SITE ADDRESS C�I T_ A I t,r 1-e (ci 32 i <br /> G Streumber Direction 6 \ Stree!Nema '"l CICt CA <br /> ZipCode <br /> HOME Or MAILING ADDRESS (If Different from Site ddress) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( ,ac`'1) 6�;). <br /> PHONE#2T• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Ck `i S CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> (H <br /> l C w ci tl — <br /> HOMEorMAILINGAD RESS _ SAX73 # ) <br /> CITY STA 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 applic 19n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA Ed FEDE L ws. ll <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGER ❑ OTHER AUTHOmZED AGENT El <br /> IJAPPLICANT is not the BILLING PARTY,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 same time it is <br /> provided to me or my representative. w <br /> TYPE OF SERVICE REQUESTED: W—" AYI�J <br /> COMMENTS: <br /> SEP r [C <br /> Sq/y J pq '1 ZO21 <br /> H OFp FNTAI"n <br /> ACCEPTED BY: EMPLOYEE#: DATE: —I <br /> ASSIGNED TO: ^ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: O <br /> Fee Amount: I r Amount P I /v e oD Payment Date <br /> Payment Type Invoice# Check# Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> �oal�ol 13� S <br />