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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (-Yu <br /> g5 <br /> OWNER OPERATOR <br /> A-L-V-1 e-1--,- CHECK If BILLING ADDRESS <br /> FACILITY NAME r� <br /> ,(A <br /> SITE ADDRESS Z <br /> Street Number Direction Street Name City <br /> Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> / 4L:: Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'l EXT. APN# LAND USE APPLICATION# <br /> (2 ) l 3 -3( (,' - s& v - : — <br /> PHONE#2 Ex-r. BOS DISTRICT 5 LOCATION C <br /> ( ► l� <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR PLl ` ,l CHECK If BILLING ADDRESS <br /> BUSINESS NAME IL'1^— PHONE# EXT. <br /> ( ► <br /> HOME or MAILING ADDRESS FAX# <br /> �o 0--e Z z 7YS- ( ► <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,_ TATE and-F-FO laws. <br /> APPLICANT'S SIGNATUR _DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is require/d\ Tule <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. 1 I (� -PA <br /> TYPE OF SERVICE REQUESTED: SO i 5:� �G, , 1 r o✓! nJ Ll / % I re,to I.Or.'p�11'N �f v rj P P <br /> COMMENTS: JUL <br /> AQUIN CpuN <br /> HE4LTH 0FpAR M L <br /> ACCEPTED BY: 1. EMPLOYEE#: DATE: <br /> ASSIGNED TO: ✓Ill EMPLOYEE#: DATE: 7 s' <br /> Date Service Completed (if already completed): SERVICE CODE: 3 P/E: a �� <br /> Fee Amount: L Amount Pai &2 Z)Z) Payment Date <br /> Payment Type Invoice# Check# T� G Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />