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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �Y�JD <br /> OWN /OPERA OR 'I <br /> n 1V CHECK If BILLING ADDRESS <br /> I <br /> FACILITY AME/ <br /> SITE ADDRESS 30 <br /> S Street Number I Direction C.011tfebtNama kl- <br /> HOME or MAILING A R SS (If Diffe ent from Site Address) <br /> 16 Street Number Street Name <br /> CITY ST TE ZIP <br /> 1 . <br /> PHONE#1 Fm. APN# LAND USE APPLICATION# <br /> PHONE#2 Exr. BOS DIS CT LOCATION CODE <br /> ( ) 53c)- DS-2-1tDl a1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS El <br /> BUSINESS NAME PHONE# EXT. <br /> 1 ) <br /> HOME or MAILING ADDRESS FAX# <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 and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA ,and FEDERAL laws. <br /> APPLICANT'S SIGNATU�.R,{/E: ll — DATE: 2 <br /> PROPERTY/BUSINESS OWNERIIC.I OPERATOR/MANAGER OTHER AUTHORrzED AGENT 13 <br /> IfAPPL1CANT is not the B/LLINC PAR7Y 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 environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available andlyne time it is <br /> provided to me or my representative. fne; <br /> TYPE OF SERVICE REQUESTED: A �ClvCD <br /> COMMENTS: <br /> �0 <br /> RO UlA CCU <br /> ASSIGNED TO: C IktA ( Z <br /> 2J <br /> FACTN p dNfNTU TY <br /> ENT <br /> ACCEPTED BY: W, /V EMPLOYEE#: DATE: <br /> •�i1.0�-YL5 EMPLOYEE#: DATE: g-,26 ']-t <br /> Date Service Completed (if already completed): SERVICE CODE: ( P/E: [ LO-2, <br /> Fee Amount: L S 'L,IJD Amount Paid 15 2 _ Payment Date D 1'2-(-Pi 2-1 <br /> Payment Type Invoice# I 3Z Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 ���� <br />