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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> RASk .►zt Ff� CYC l�)1''6 1 '5�La N <br /> OWNER/OPERAT <br /> If I 1� ILO t7 11W CHECK If BILLING ADDRESS <br /> FACILITY NAME Z <br /> SITEADDRESS ,,f r I1 rl„ I' <br /> Street Number Direction 17+1 -(r Street Name Ca, <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY /J �r'� STATE ZIP <br /> PHONE#1 L� b S V E� APN# LAND USE APPLICATION# <br /> ( <br /> PHONE#2 EXr. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1A CRY i <br /> CHECK M BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ezr. <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY Kb <br /> STATE Oq ZIP quo <br /> BILLING ACKNOWLEDGEMENT: 1, 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 atA FEDERALIaws. <br /> APPLICANT'S SIGNATURE: DATE: y� <br /> PROPERTY/BUsINESs OWNER❑ OPE 'OR/MAN ER OTHER AUTHORIZED AGENT❑ <br /> ffAPPL/CANT 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. P <br /> TYPE OF SERVICE REQUESTED: Fc N <br /> COMMENTS: <br /> FFB <br /> /yFq��y�CQ MF o�N? <br /> FpgR�� lY <br /> ACCEPTED BY: ��� EMPLOYEE M DATE: 2-2-:S-2 <br /> ASSIGNEDTO: L ; ���f Q EMPLOYEEM DATE: 2- 2 �J— 2 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE ` ()2 <br /> Fee Amount: Amount Paid li5 Payment Date 2 <br /> Payment Type `S Invoice# Check# J39s�vl� Received By: an <br /> EHD 48-02-025 C�n� # \3g51�q �Z SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />