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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FA �� j 2� , R o0 ��18 <br /> CVVQERI OPERATOR <br /> CHECK If BILLING ADDRESS <br /> L <br /> FACILITY NAME <br /> SITE,A,9DRESS 7CJI�{1 <br /> 7 t 1 Street Number Direet[on V Stree Name C* <br /> HOME or M rr?[R%f Different from Site Address) <br /> Street Number treat Nam <br /> CITY STATE�l SEZIP <br /> PHONE#I Err. APN# LAND USE APPLICATION# <br /> ( ) tond 0 U 4.3.20- /LI <br /> PHONE � i/ XT• BOS DISTRICT LOCATION CODE <br /> CONTRACTO / SERVICE REQUESTOR <br /> REQUESTO <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# <br /> HOME or MAILING ADD FAx# <br /> CITY A?ZSTATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned roperty or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENv1R0 E�TAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identi led on his to . <br /> I also certify that I have prepared this application and at the to be erformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar TATE an FE ERAL la ( � ���777 <br /> APPLICANT'S SIGNATURE: DATE: Z Z - Z07L <br /> PROPERTY/BUSINESS OwNERI, OP 'OR/MAN CLE. ❑ OTHER AUTHORIZED AGENT 11 <br /> IJ'APPLLCANT 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 Saltie time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: -- PAYMENT <br /> COMMENTS: IVED <br /> APR 2 2 1022 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPART <br /> ACCEPTED BY: -CUI EMPLOYEE#: 7441 DATE: V <br /> /7Og <br /> ASSIGNED TO: / EMPLOYEE#: rr DATE: ' �J <br /> Date Service Completed (if already Completed): C. SERVICE CODE: PIE: fis <br /> Fee Amount: `] Amount Paid / J['� Payment Date Z <br /> Payment Type G� 5 Invoice# Check# Received By: <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> P Roil �22`� <br />