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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of B�es�r Prope�� � FACILITY ID# SERVICE�'UEST# <br /> OWNER I OPERATOR / ), CHECK If BILLING ADDRESS <br /> FACIL NAME l` gy„_ r,`\ ��, q J <br /> SITE AooR t 1t N---/ o <br /> C 5!h/ea✓t Number Direction Street Nama r� C a <br /> HOME or MAILING ADDRESS (If Wife nt fro,/mJSit'er A/dd s(,w/e <br /> ~ Uv 0 M " e'Streel Number Street Name <br /> CITY L��G ,. I �, ^ _ STA t ZIP f <br /> PHONE#1 Ear• APN# LAND USE APPLICATION# <br /> PHONE#2 Ex. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME % U y� PHO ' -, Eat <br /> 65 a 14 L <br /> HOMEDr MAILIN ADDRE S FAX# <br /> 7 " � e uA Ve ( <br /> CITY �/-` / G/ISTATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent iof 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. yq <br /> APPLICANT'S SIGNATURE:�`' - Z--" DATE: �! / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> !f APPLICANT isnot the BILLING PARTS 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 environmentaHe assessment <br /> Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at tlt •��r,„�e it is <br /> provided to me or my representative. " ' '^F^ <br /> TYPE OF SERVICE REQUESTED: i � ) o kA I Q <br /> COMMENTS: <br /> �RCU/N c <br /> HEiC1h�Ep'HFN�N7y <br /> ENT <br /> ACCEPTED BY: Q`rq-eS G(5 EMPLOYEE#: DATE: !� <br /> ASSIGNED TO: `J EMPLOYEE#: DATE: SS -� <br /> Date Service Completed (if already aomplet ): SERVICE CODE: P1 Q <br /> Fee Amount: —' Amount Paid ' 'J Payment Date 5/ Z Z <br /> Payment Type 2 1,0 <br /> kk Invoice# Check# Received <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 c <br />