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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FIA`IG ID#� SERVICE REQUEST# <br /> 310 AM <br /> PLOV <br /> +0 ER./ P_ERATOCR:;1fAol V <br /> CHECK If BILLING ADDRESS <br /> FACILITY-NAMO <br /> CSRE ADDRESS> �t J /1 (Tr /aCJLQ <br /> Street Number Dlreotlon 1 Street Name C.� Cit Y ZI Code <br /> (HOME or MAILING' ADDRESS (If Different from Site Address) <br /> Adr e Street Number Street Name <br /> �CITX�, STATE ZIP <br /> --/ fioc.K.1-u n c c� qs z is <br /> I•PHONE#J+, E� . APN# LAND USE APPLICATION# <br /> (Slo ) -11 co- G1 colo <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> I_REQU E5TOR I CHECK If BILLING ADDRESS E] <br /> (BUSINESS NAME' ..PHONE#J3 Ext. <br /> (HOME-or-MAILING ADDRESS FAX# .. <br /> _ l ) <br /> �ITY-1 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,STATE and F"", <br /> laws. <br /> APPLICANT'S SIGNATURE: t-D <br /> I - -• - -- <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> 1fAPPL/CANT is not the B/LLINCPARTY 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 this <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: D <br /> COMMENTS: <br /> 04 <br /> ACTH OLIN <br /> DnfN�ROAf, M N <br /> Q <br /> ACCEPTED BY. C, EMPLOYEE#: DATE: <br /> ASSIGNED TO: T w� EMPLOYEE#: DATE: <br /> Date Service Completed (if air ea completed): SERVICE CODE: P/E: <br /> Fee Amount: 2 Amount Pai /S� v Payment Date u 2Z <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />