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SAN JOAQUIN 2OUNTY ENVIRONMENTAL HEALTH 1,EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVI#VtQUEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITEADDRESS -27l a ,� 1,c OB/A/OL e-,—_ ] moo^! rap <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) �oZa9 L.�4NE� S w/TE,Q <br /> Street/Number Street Name <br /> CITY STATE ZIP <br /> o C e14 SaO <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 Ma. BOS DISTRICT q LOCATE CODE <br /> ( ) lY <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR N � CHECK if BILLING ADDRESS <br /> 17 o �f� <br /> BUSINESS NAME PHONE# EXT. <br /> OYL51"fE , a > z sa <br /> HOME or MAILI DDRESS <br /> FAx <br /> ox 3 ( ) <br /> CITY STATE/J� 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 apation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards T TE and F L laws. <br /> APPLICANT'S SIGNATURE: DATE; / a <br /> PROPERTY/BUSINESS OWNER El OPE RATO /MANAGER ❑ OT HER AUTHORIZED AGENT <br /> IfAPPLiCANT 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 asame time it is <br /> provided to me or my representative. A� <br /> TYPE OF SERVICE REQUESTED: S C� xZ�e V/E <br /> COMMENTS: SA]V Jd�� <br /> Il i!ONE DUlyn, <br /> H pFp'MFNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE DATE: GZ� <br /> Date Service Completed (if already completed): SERVICE CODE: l 3 P/E. 6 O? <br /> Fee Amount: (:)`) Amount Paid 3a/-�1._0(> I <br /> Payment Date 3/rte/zL <br /> Payment Type !� Invoice# Check# Received By:/ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />