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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> U <br /> OW IOPERAATOR CHECK If BILLING ADDRESS <br /> Or <br /> A', Trn to <br /> FACILITY NAME <br /> SITE ADDRESS r� _/ �r ( /� � r ,)/-I-I.n 1�.7 <br /> neat Number Direc lon O( tree Nalene I v'\��l I I Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> w A4 V Street Number street Name <br /> CITY STATE ZIP <br /> U d C <br /> PHONE#1 E`T APN# LAND USE APPLICATION# <br /> (u, ) bfy <br /> PHONE#2 ExT• SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE RE ESTO <br /> R`QUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> Co. ) Z�ly 2-O p� bf U <br /> HOME or MAILING ADDRESS FAX# <br /> 1736 ti Y �h • ( ) <br /> CITY 1 ,14 -f 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE:,�'-/Z 7/Z-2. <br /> PROPERTY/BUSINESS OWNERr PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <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 envirote assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available aQ�j le it is <br /> provided to the or my representative. /v <br /> TYPE OF SERVICE REQUESTED: MAY <br /> COMMENTS: _ J <br /> qQU/N ?c <br /> Afr <br /> ��FNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 5 7 <br /> ASSIGNEDTO: '� EMPLOYEE#: DATE: S012-2 <br /> DateDate Service Complete (if already completed): SERVICE CODE: P/E: I D3 <br /> Fee Amount: 2 G"tl Amount Paid (� '� Payment Date <br /> Payment Type Cl Invoice# 2 I-J 4 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) _ <br /> REVISED 11/17/2003 <br />