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SAN JOAQUIN COUNTY EINVIRONNIENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property r A de 2 O e 4 � _SIC� �S'' � <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME I1 ,a\ � � `^` ` \Z, <br /> G� <br /> SITE ADDRESS ,L\2—L\2— <br /> V v C L Code <br /> Q—\L\2— <br /> Number Direction Street Name <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 2-1 5 to <br /> Street Number Street Name <br /> STATE ZIP ��T <br /> CITY r'N <br /> EXr. APN# LAND USE APPLICATION# <br /> PHONE#1 <br /> ( M)q <br /> EXT. [BOS DISTRICT LOCATION CODE <br /> PHONE#Z <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> CHECK if BILLING ADDRESS❑ <br /> REQUESTOR <br /> TFAx <br /> EXT. <br /> BUSINESS NAME <br /> HOME or MAILING ADDRESS ) <br /> STATE ZIP <br /> CITY <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 FEDERAL,laws. <br /> APPLICANT'S SIGNATURE: �15Z:�N' �-6 DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PART}.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 avail�L1N <br /> �une time it is <br /> provided to me or my representative. JJ��T 1��G <br /> TYPE OF SERVICE REQUESTED: JUN 1 <br /> COMMENTS: <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> _Ac- <br /> CEPTEDBY: aln EMPLOYEE#: DATE: <br /> YYYYIIII EMPLOYEE#: DATE' <br /> ASSIGNED TO: jo ,e— 'Z <br /> Date Service Completed (if already completed): SERVICE CODE: x 4 C P 1 E: O Z <br /> Fee Amount: Amount Paid � Payment Date [P 13 02 <br /> Payment Type Invoice# Check# Received By: aa4t <br /> EHD 48-02-025 SR FORM(Golden:Rod) <br /> REVISED 11/17/2003 <br />